Introduction
Intraosseous (IO) line placement is a skill that should be mastered by all physicians. In the setting of pediatric hypotension, peripheral vascular access may become difficult, or even impossible due to venous collapse. Placement of an IO may be a life-saving measure, as it is an extremely useful tool for the rapid infusion of intravenous fluids, blood, or medications. IO access requires less skill and practice than central line and umbilical line placement. With IO placement, access to the central circulation through veins in the marrow can be achieved in seconds. It should be considered after three failed attempts at peripheral venous access in the acutely ill child. ‚
IO placement is most useful in neonates and children younger than 5 years of age because complete ossification of bones has not yet occurred, though it may be considered in adults as well. In children, the preferred site of infusion in the medial aspect of the proximal tibia. Other possible sites of infusion may include the distal femur, proximal hummers, ileum, or clavicle. In adults, the most common site of infusion is the medial malleolus, though the sternum may be considered as well. ‚
View OriginalView Original
Equipment
- Sterile gloves
- Povidone-iodine (Betadine) or chlorhexidine gluconate (Hibiclens, others) solution. See Appendix E.
- Sterile drapes
- 3-cc syringe with 1% " ‚lidocaine for local anesthesia
- Disposable IO needle (16 or 18 gauge) that contains an inner stylet
- 10-cc syringe
- Sterile flush
- IV fluids and tubing
Indications
- Rapid vascular access in neonates and children for the infusion of IV fluids, blood, and medications
Contraindications
- Open tibial fracture
- Previous attempt on the same leg bone
- Overlying skin infection (relative)
- Osteogenesis imperfecta because of a higher likelihood of fractures occurring (relative)
- Osteopetrosis (relative)
The Procedure
Step 1
Obtain informed consent if caregiver or guardian if available. Identify proper puncture site approximately 2 cm below tibial tuberosity on medial surface of tibia. ‚
Step 1 View Original Step 1 View Original
Step 2
Prepare the skin with povidone-iodine or chlorhexidine solution, and drape the skin using sterile technique. Using 25-gauge (or less) needle attached to 3-cc syringe, anesthetize skin and subcutaneous tissue overlying puncture site. Insert the IO needle through the skin and underlying tissue. Stop when you reach the bone. Stabilize needle using your index finger and thumb. ‚
- PEARL: If initial skin penetration is difficult, a small incision made with a scalpel may be necessary prior to insertion.
- PEARL: The physician should not place his or her hand underneath the knee (popliteal fossa area.) This is a safety precaution to prevent possible lacerations and through-and-through penetration during insertion.
Step 2 View Original Step 2 View Original
Step 3
Using the opposite hand, apply downward pressure and clockwise twisting motion of the palm of the hand; puncture the IO needle through cortex of tibia at a 30-degree angle. The bone will give way when you enter the marrow cavity. The needle should feel secure and nonmobile if placed properly. ‚
- PITFALL: Be careful not to insert needle all the way through the cortex on the opposite side, as this puts the patient at risk for extravasation of fluid into the calf muscle and compartment syndrome.
Step 3 View Original Step 3 View Original
Step 4
Carefully unscrew inner stylet of IO needle. Attach 10-cc syringe and aspirate for blood return (may be absent in shock). Attempt to flush 5 cc to 10 cc of fluid through the IO. Infusion should occur easily. Watch for extravasation in the surrounding tissues, including the calf muscle. Secure using tape and gauze. ‚
- PEARL: Inability to aspirate blood does not indicate improper placement.
Step 4 View Original Step 4 View Original
Complications
- Fracture of the tibia
- Growth plate disruption
- Hematoma
- Infiltration of surrounding tissues with extravasated fluids
- Cellulitis of overlying skin
- Osteomyelitis
- Fat emboli
- Compartment syndrome
- Muscle necrosis secondary to extravasation of hypertonic or caustic medications, such as sodium bicarbonate, dopamine, or calcium chloride.
Postprocedure Instructions
After securing the IO line and stabilizing the patient, alternative sites of vascular access should be sought out. Ideally, the IO line should be removed within the first several hours after placement so as to decrease the likelihood of complications; however, it may be left in place for up to 72 hours if necessary. The infusion of IV antibiotics should begin immediately after the IO line is placed to prevent cellulitis of the leg and/or osteomyelitis. ‚
Coding Information and Supply Sources
‚
View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 36680 Intraosseous Line Placement $252.00 0 CPT is a registered trademark of the American Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008 MMH-SI 's copyrighted Physicians ' Fees and Coding Guide.
ICD-9 Codes
‚
View Large Hypovolemic shock 785.59 Dehydration 276.51 Hemorrhage 459.00
Supplies can be obtained from: ‚
- EZ-IO needle. Vidacare Corporation, 722 Isom Road, San Antonio, TX 78216. Phone: 1-866-479-8500. Web site: http://www.vidacare.com/.
- Jamshidi needle. Baxter Healthcare Corp, One Baxter Parkway, Deerfield, IL 60015-4625. Phone: 1-800-422-9837. Web site: http://www.baxter.com/products/index.html.
Bibliography
1
Abe ‚ KK, Blum ‚ GT, Yamamoto ‚ LG. Intraosseous is faster and easier than umbilical venous catheterization in newborn emergency vascular access models.
Am J Emerg Med
. 2000;18(2):126 " “129. ‚ [View Abstract]
2
Berk ‚ WA, Sutariya ‚ B. Vascular access. In: Tintinalli ‚ JE, Kelen ‚ GD, Stapczynski ‚ JS.
Emergency Medicine A Comprehensive Study Guide
. New York: McGraw-Hill; 2004:130 " “131. 3
Gluckman ‚ W, Forti ‚ R, Lamba ‚ S. Intraosseous Cannulation. Available at: Emedicine.com. http://www.emedicine.com/ped/TOPIC2557.HTM. Accessed November
1, 2008. 4
Guy ‚ J, Haley ‚ K, Zuspan ‚ SJ. Use of intraosseous infusion in the pediatric trauma patient.
J Pediatr Surg.
1993;28(2):158 " “161. Hodge D 3rd. Intraosseous infusions: a review.
Pediatr Emerg Care
1985;1(4):215 " “218
5
Rosetti ‚ VA, Thompson ‚ BM, Miller ‚ J. Intraosseous infusion: an alternative route of pediatric intravascular access.
Ann Emerg Med
. 1985;14(9):885 " “888. 6
Smith ‚ R, Davis ‚ N, Bouamra ‚ O. The utilisation of intraosseous infusion in the resuscitation of paediatric major trauma patients.
Injury
2005;36(9):1034 " “1038; discussion 1039. 7
2008 MAG Mutual Healthcare Solutions, Inc. 's
Physicians ' Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc.
2007.