3. Intraosseous Infusion

Intraosseous Infusion

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

Synonym: intraosseous transfusion

More aptly referred to as intraosseous 'infusion' than 'transfusion' as the route is usually used for the infusion of fluids rather than for blood transfusion.

Bone marrow is a very vascular tissue and, as such, it can be a useful route to gain vascular access, usually in children. The technique of intraosseous infusion was first described in humans in 1934 and it became increasingly popular in the 1940s. The use of the intraosseous route is still regarded as somewhat controversial in many quarters. It has gained considerable acceptance over the past 20 years, especially in critically ill or injured children, often with trauma or burns.

It is usually reserved for children but can be employed at any age. The technique may appear to be strictly for the specialist but gaining intravenous access in children can be extremely difficult and require great skill. This technique has few contra-indications and the success rate is very high, even when performed by paramedical personnel, whilst the rate of complications is very low. It tends to be restricted for use in children in crisis such as cardiac arrest, shock, trauma, life-threatening status epilepticus, or any situation in which the potential benefit of rapid venous access outweighs the low incidence of complications.[1]

Intraosseous infusion is also now preferred over endotracheal route to administer drugs during advanced life support in adults (endotracheal route being no longer used).[2] Saphenous vein cutdown has now almost completely disappeared in favour of the intraosseous route in children. It remains available even in shock and is indicated in an emergency when other methods are unavailable or unsuitable. In the neonate it may be easier and quicker than umbilical vein catheterisation in an emergency. It has a very good outcome in neonatal resuscitation where other attempts at vascular access have failed.[3] Use for neonatal resuscitation is supported by international guidelines.[4]

The current guidelines of the European Resuscitation Council (ERC) stipulate that intraosseous access should be used if establishing a peripheral venous access for cardiopulmonary resuscitation (CPR) would involve delays.[5]

Guidelines state that, during CPR in children younger than 6 years, intraosseous access should be obtained if there is inability to achieve reliable venous access after three attempts or 90 seconds, whichever comes sooner. Intraosseous access has the same benefits in children aged over 6 years but access to the anterior tibial marrow is more difficult and other sites such as the lower femur, iliac crest or sternum should be considered.

  • It can be considered in other situations too where there is circulatory collapse, as in severe dehydration and diabetic ketoacidosis.[6][7]
  • It also gives access for rapid delivery of fluids in children with burns.[8]
  • It can even be used in neonates, although is not often required because of easy umbilical venous access.[9]
  • It is possible to give all resuscitation fluids and drugs except bretylium.
  • It is possible to achieve high flow rates especially if using a syringe to infuse fluid.
  • It can be used to administer blood.[10]
  • It can be used to administer drugs and achieves adequate plasma concentrations in a time comparable with injection through a central venous catheter.[5]
  • It also enables withdrawal of marrow for venous blood gas analysis and measurement of electrolytes and haemoglobin concentration.[5]

Relative contra-indications include fractured limb, local infection or osteomyelitis and severe bone disease, especially osteogenesis imperfecta.

  • This description is based on that provided by Médecins sans Frontières and the reader is recommended their website as listed at the end.
  • Ideally this should be a sterile procedure using a specific needle but it is possible to use a bone marrow aspiration needle or any 14-20 gauge needle with an internal stylus in an emergency. Even use of a butterfly needle is reported.[7]
  • Palpate the tibial tuberosity. The site for cannulation lies 2-3 cm below this tuberosity on the anteromedial surface of the tibia. An insertion site of at least 10 mm distal to the tibial tuberosity is recommended to avoid injury to the epiphyseal growth plate and to ensure ease of insertion.[11]
  • Use sterile gloves with an aseptic technique and a sterile needle. Clean the skin. Placing a bone marrow needle without using a sterile technique increases the risk of osteomyelitis and cellulitis.
  • Inject a small amount of local anaesthetic in the skin and continue to infiltrate down to the periosteum. This is unnecessary in an unconscious child.
  • Flex the knee and put a firm support behind the knee.
  • Hold the limb firmly above the site of insertion, usually at the level of the knee. Avoid putting your hand behind the site of insertion to avoid accidentally injuring your own hand.
  • Insert the intraosseous needle perpendicular to the skin and slightly caudal (towards the foot) to avoid the epiphysial growth plate.
  • Advance the needle using a drilling motion until a 'give' is felt. This occurs when the needle penetrates the cortex of the bone. Stop inserting further.
  • Remove the trochar. Confirm the correct position by aspirating blood using a 5 ml syringe. If no blood can be aspirated the needle may be blocked with marrow. To unblock the needle, slowly syringe in 10 ml of saline.
  • Check that the limb does not swell up and that there is no increase in resistance.
  • If the tests are unsuccessful, remove the needle and try the other leg.
  • Connect to an infusion set with a short extension and three-way tap to reduce traction on the needle. Immobilise the access with a dressing and tension relief with adhesive tape between the leg and the infusion set.

Correct placement is further confirmed by:

  • A sudden loss of resistance on entering the marrow cavity. This is less obvious in infants as they have soft bones.
  • The needle remains upright without support. Because infants have softer bones, the needle will not stand as firmly upright as in older children.
  • Fluid flows freely through the needle without swelling of the subcutaneous tissue.

Change to venous access as soon as adequate resuscitation is achieved.

Newer devices, such as the 'bone injection gun' (BIG), may increase the use of this route.[12] It may be a little quicker to use[13][14] and it may even be suitable for mass use in chemical warfare where there are many casualties needing vascular access and staff are encumbered by personal protective equipment (PPE) clothes.[15] The powered device is also safe for use in children.[16]

Complications from intraosseous access are rare:

  • Pain can be significant and this should be borne in mind when using the technique. Adequate local anaesthetic should be used in conscious patients. One report suggested pain from use of this technique was more significant than the injuries being treated in some patients.[17]
  • Fractures and osteomyelitis after long-term use or when hypertonic solutions have been used.
  • Fat embolism is less likely in children than in adults and has minimal clinical consequences.
  • Local extravasation of fluids due to incomplete penetration of the needle into the cortex, intraosseous infusion into a fractured limb, or perforation of the bone may lead to a compartment syndrome.[18]
  • Follow-up in neonates has excluded concerns about injury to growing bone and the growth plate.[19]
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Further reading & references

  • Mackway-Jones KME, Phillips B, Wieteska S: Intraosseous transfusion. In Advanced Paediatric Life Support 3 Edition (Edited by: Group ALS). London: BMJ Books 2001, 229-230
  • Intraosseous infusion, Médecins sans Frontières
  • Bosomworth NJ; The occasional intraosseous infusion. Can J Rural Med. 2008 Spring;13(2):80-3.
  1. Jaimovich DG, Kecskes S; Intraosseous infusion: a re-discovered procedure as an alternative for pediatric vascular access.; Indian J Pediatr. 1991 May-Jun;58(3):329-34.
  2. Adult Advanced Life Support, Resuscitation Council UK Guideline (2010)
  3. Ellemunter H, Simma B, Trawoger R, et al; Intraosseous lines in preterm and full term neonates.; Arch Dis Child Fetal Neonatal Ed. 1999 Jan;80(1):F74-5.
  4. Niermeyer S, Kattwinkel J, Van Reempts P, et al; International Guidelines for Neonatal Resuscitation: An excerpt from the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Contributors and Reviewers for the Neonatal Resuscitation Guidelines.; Pediatrics. 2000 Sep;106(3):E29.
  5. European Resuscitation Council Guidelines
  6. Alawi KA, Morrison GC, Fraser DD, et al; Insulin infusion via an intraosseous needle in diabetic ketoacidosis. Anaesth Intensive Care. 2008 Jan;36(1):110-2.
  7. Daga SR, Gosavi DV, Verma B; Intraosseous access using butterfly needle.; Trop Doct. 1999 Jul;29(3):142-4.
  8. Goldstein B, Doody D, Briggs S; Emergency intraosseous infusion in severely burned children.; Pediatr Emerg Care. 1990 Sep;6(3):195-7.
  9. DeBoer S, Russell T, Seaver M, et al; Infant intraosseous infusion. Neonatal Netw. 2008 Jan-Feb;27(1):25-32.
  10. Guy J, Haley K, Zuspan SJ; Use of intraosseous infusion in the pediatric trauma patient.; J Pediatr Surg. 1993 Feb;28(2):158-61.
  11. Boon JM, Gorry DL, Meiring JH; Finding an ideal site for intraosseous infusion of the tibia: an anatomical study.; Clin Anat. 2003 Jan;16(1):15-8.
  12. Schwartz D, Amir L, Dichter R, et al; The use of a powered device for intraosseous drug and fluid administration in a national EMS: a 4-year experience. J Trauma. 2008 Mar;64(3):650-4; discussion 654-5.
  13. Curran A, Sen A; Best evidence topic report. Bone injection gun placement of intraosseous needles.; Emerg Med J. 2005 May;22(5):366.
  14. Brenner T, Bernhard M, Helm M, et al; Comparison of two intraosseous infusion systems for adult emergency medical use. Resuscitation. 2008 Jun 21;.
  15. Vardi A, Berkenstadt H, Levin I, et al; Intraosseous vascular access in the treatment of chemical warfare casualties assessed by advanced simulation: proposed alteration of treatment protocol.; Anesth Analg. 2004 Jun;98(6):1753-8, table of contents.
  16. Horton MA, Beamer C; Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients. Pediatr Emerg Care. 2008 Jun;24(6):347-50.
  17. Cooper BR, Mahoney PF, Hodgetts TJ, et al; Intra-osseous access (EZ-IO) for resuscitation: UK military combat experience. J R Army Med Corps. 2007 Dec;153(4):314-6.
  18. Wright R, Reynolds SL, Nachtsheim B; Compartment syndrome secondary to prolonged intraosseous infusion.; Pediatr Emerg Care. 1994 Jun;10(3):157-9.
  19. Fiser RT, Walker WM, Seibert JJ, et al; Tibial length following intraosseous infusion: a prospective, radiographic analysis.; Pediatr Emerg Care. 1997 Jun;13(3):186-8.
Original Author: Dr Richard Draper Current Version:
Last Checked: 18/02/2011 Document ID: 1012  Version: 22 © EMIS

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

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