Intraosseous Needle Insertion

1
Intraosseous Needle Insertion

• Kalpesh Patel, MD
• Dept. of Pediatric Emergency Medicine
• November 22, 2006

2
Objectives

• Understand the history of intraosseous needles
  (IO)
• Understand the indications, risks, and benefits
  of IO needle insertion
• Learn to perform
• IO needle insertion at various locations using
  the manual insertion method
• IO needle insertion using new techniques

3
History

• Earliest reference to IO use was in 1922
• First theraputic use in humans was reported in
  1934
• Popularized in the 1940s for rapid access
• Used widely until 1950s when the plastic
  catheter was devised
• Reemerged in mid 80s for resuscitation where IV
  access was difficult
• Since then, pediatric use has become more
  accepted
• Now used as the standard of care for emergency
  access in both pediatrics and adults

4
Physiology

• The marrow cavity is in continuity with the
  venous circulation and functions as a
  non-collapsable venous plexus
• Sinusoids serve as transport to the central
  venous channel exiting as nutrient and emissary
  veins

5
Physiology

• The onset of action and drug levels during CPR
  using the IO route are similar to those given IV
  
• Used to infuse fluids, blood products, and drugs
• Can take mixed venous blood samples for labs such
  as crossmatch, bedside tests, etc.

6
Indications

• When vascular access is needed in
  life-threatening situations
• When attempts at standard venous access fail
  (three attempts or 90 seconds) or in cases where
  it is likely to fail and speed is of the essence.

7
Contraindications

• Femoral fracture on the ipsilateral side
• Do not use fractured bones
• Do not use bones with osteomyelitis
• Osteogenesis Imperfecta
• Osteopetrosis

8
Types of IO Needles
Jamshidi IO Needle
Cook IO Needle
Sur-Fast IO Screw Tip Needle
Illinois Sternal Iliac Needle
9
Equipment Required

• Antiseptic prep solution
• Local Anesthetic (optional in the moribund
  patient)
• IO Needles
• 18-20 gauge spinal needle can be used as an
  alternative
• In a pinch, any needle can be used, but may get
  clogged with cortical bone without stylet or
  trochar
• Syringe
• Flush solution
• Gauze pads and tape

10
Locations of Insertion

• 3 most common locations
• Proximal Tibia
• Medial side, 1-2 cm below and avoiding the tibial
  tuberosity

11
Locations of Insertion

• Distal Femur
• Femur is triangular shaped. Insert needle 1-2 cm
  proximal to the superior border of patella and
  medial or lateral to anterior ridge
• Distal Tibia
• 1-2 cm proximal to the medial malleolus in the
  center of the bone

12
Locations of Insertion

• In older children and adults
• Iliac crests, preferably Anterior Superior Iliac
  Spine
• Sternum

13
Technique for Manual Insertion

• Prep the site
• Inject 1-3 ml of lidocaine into the skin and down
  to the periosteum (optional when time does not
  permit this)
• Grasp needle in dominant hand and place it on the
  site with the needle pointing away from the joint
• Pinch needle with thumb and forefinger and allow
  the hub to rest in the palm of your hand
• DO NOT PLACE YOUR OTHER HAND BENEATH THE SITE

14
Technique for Manual Insertion

• Use firm downward pressure and rotate the needle
  back and forth
• Feel for a sudden decrease in resistance or a
  popping sound and advance the needle a few
  millimeters
• Remove the trochar or stylet and aspirate marrow

15
Technique for Manual Insertion

• Infuse fluid to determine ease of flow and no
  extravasation in to soft tissues around the
  insertion site
• Secure the needle with goal post taping to allow
  visualization of the site
• If the needle fails, then insert into a new bone
  because fluid will leak from the failed site

16
IO Insertion
http//www.cookmedical.com/cc/datasheetMedia.do?me
diaId1528id1347
17
Complications

• Through and through penetration
• Extravasation of fluids or medications into
  subcutaneous tissue
• Compartment syndrome
• Subcutaneous abscess/skin necrosis
• Osteomyelitis
• When an aseptic technique is used, the incidence
  of osteomyelitis is less than 1
• Bacteremia
• Epiphyseal injury and fracture (especially in
  neonates)
• Fat Embolus
• Bent needle
• Complications are reported to occur in lt1 of
  cases

18
New Methods

• F.A.S.T -1 system
• Bone Injection Gun (BIG)
• EZ-IO Drill

19
F.A.S.T. -1 Sternal Intraosseous Device

• First Access for Shock and Trauma
• Created for insertion into manubrium of adult
  sternum
• May be used in older children
• http//www.pyng.com/movies/iousemovie.html

20
Bone Injection Gun

• Spring loaded catheter injected into place at a
  preset depth
• Comes in Adult and Pediatric sizes
• Establishes access within 1 minute

21
BIG, The Movie
http//www.ps-med.com/big/description_big01.html
22
EZ-IO

• A battery powered electric drill which places the
  needle quickly into place

23
EZ-IO Insertion
http//www.vidacare.com/Products/index_4_29.html
24
Aftercare

• IOs are emergency lines and every effort should
  be made to place an intravenous line after
  initial resuscitation
• IOs should ideally be removed within 6-12 hours
• All IOs will eventually start to leak
• IOs can stay in for up to 48-72 hours, but after
  24 hours the risk of osteomyelitis increases
  dramatically

25
Summary

• IOs are essentially equivalent to IV access
• Should be used for emergency access
• Many types of needles exist, but Jamshidi style
  is preferred by most users
• Preferred insertion sites include proximal or
  distal tibia, or distal femur, but in older
  children, iliac crests and sternum can be
  considered
• New devices are emerging, but are not standard of
  care in pediatrics yet

26
Questions?