Intraosseous Cannulation 

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For patients in extremis from respiratory failure or shock, securing vascular access is crucial, along with establishing an airway and ensuring adequacy of breathing and ventilation. Peripheral intravenous catheter insertion is often difficult, if not impossible, in infants and young children with circulatory collapse. Intraosseous (IO) needle placement, shown in the images below, provides a route for administering fluid, blood, and medication. An IO line is as efficient as an intravenous route and can be inserted quickly, even in the most poorly perfused patients.

The use of IO access has gained acceptance over the past 15 years, but the technique has been used since the 1930s. It lost its popularity to the plastic intravenous catheters but saw a revival in the 1980s because numerous studies demonstrated the efficacy of IO administration of emergency medications in patients needing resuscitation in whom establishing intravenous (IV) access is difficult. Historically, IO use was recommended only in children younger than 6 years. However, current guidelines for cardiopulmonary resuscitation support the use of IO techniques in patients of all ages. Successful use in adults has been reported. IO access requires less skill and practice than central line and umbilical line placement. IO techniques have fewer serious complications than central lines and can be performed much faster than central or peripheral lines when vascular collapse is present. [1, 2, 3]

The marrow of long bones has a rich network of vessels that drain into a central venous canal, emissary veins, and, ultimately, the central circulation. Therefore, the bone marrow functions as a noncollapsible venous access route when peripheral veins may have collapsed because of vasoconstriction. This approach is particularly important in patients in shock or cardiac arrest, when blood is shunted to the core due to compensatory peripheral vasoconstriction. The intraosseous (IO) route allows medications and fluids to enter the central circulation within seconds.

The levels of drugs, chemistries, and hemoglobin, as well as acid-base status, obtained from bone marrow are reliable predictors of serum levels.

The risks and complications of intraosseous (IO) insertion are few, and the benefits far outweigh the risks in a child without intravenous (IV) access who needs rapid administration of medication or fluid.

Extravasation of fluid is the most common complication. It typically occurs when a needle is misplaced as shown below. Rarely, extravasation occurs with a properly placed needle and is associated with excessive movement during or after insertion, which may lead to enlargement of the entry site in the bone relative to the diameter of the needle.

Compartment syndrome is a risk with IO insertion. The needle must enter through the cortex and into the marrow cavity without passing through the cortex on the other side. If the needle is passed through the opposite cortex, infused fluid enters the calf rather than the venous system. If left undetected, fluid accumulation may lead to a compartment syndrome, with potential loss of the limb. Frequent checks are therefore essential. This complication can also be limited by making only one attempt per tibia. Repeated attempts in the same bone allow fluid to flow through the previous holes produced in the bone.

Extravasation of hypertonic or caustic medications, such as sodium bicarbonate, dopamine, or calcium chloride, can result in necrosis of the muscle.

Infection and osteomyelitis are relatively rare complications and occur most commonly if aseptic technique is not followed during insertion. Children with bacteremia can develop this complication, as well. Cellulitis at the insertion site has also been reported.

Other possible complications include local hematoma, pain, fracture and growth plate injuries (with incorrect placement), and fat microemboli (not clinically significant) and compartment syndrome if extravasation is not recognized upon insertion. [4, 5] With increased awareness of complications and improved training, complications may be less common than previously seen. [6]

Obtaining alternative IV access soon after the emergency and subsequent removal of the IO needle decreases the likelihood of these complications. In most instances, the goal is to remove the IO needle within 3-4 hours. IO needles may be left in place for 72-96 hours, but the risk of infection and dislodgment increase; in practice, the IO needle is removed once alternative vascular access is obtained.

Intraosseous (IO) insertion was typically recommended for use in children younger than 6 years; however, it is now recognized to be both safe and effective in older children and adults. [1, 7]

The problems with IO use in older patients arise from the increased difficulty of insertion through thicker cortex of the bone and the smaller marrow cavity. Inability to enter the marrow may increase the likelihood of fracturing the bone.

The most common site recommended for intraosseous (IO) insertion is the proximal tibia because it provides a flat surface with a thin layer of overlying tissue and ease of identifying landmarks. Also, it is distant from the airway and chest, where resuscitation attempts are in progress. The procedure for IO insertion in the proximal tibia is as follows:

Identify the tibial tuberosity, just below the knee, by palpation.

Locate a consistent flat area of bone 2 cm distal and slightly medial to the tibial tuberosity. (Identifying these landmarks helps avoid hitting the growth plate.)

Support the flexed knee by placing a towel under the calf.

If time permits, cleanse the area with an iodine solution and drape it. Perform insertion using sterile gloves and technique.

Inject local anesthetic (1% lidocaine) into the skin, into the subcutaneous tissue, and over the periosteum, especially if the patient is awake.

Insert the IO needle through the skin and subcutaneous tissue; this should occur easily. Upon reaching the bone, hold the needle with the index finger and thumb as close to the entry point as possible and, with constant pressure on the needle with the palm of the same hand, use a twisting motion to advance the needle through the cortex until reaching the marrow. A 10-15° caudal angulation may be used to further decrease the risk of hitting the growth plate, but direct entry parallel to the bone is acceptable.

Advance the needle from the cortex into the marrow space, at which point a popping sensation or lack of resistance is felt. Do not advance the needle any farther.

The first indication of proper placement occurs when the needle stands up on its own. At this point, remove the inner trocar, attach a syringe to the needle, and aspirate bone marrow. Obtaining marrow confirms placement.

If marrow is not aspirated, push a 5-mL to 10-mL bolus of isotonic sodium chloride solution through the syringe. Resistance to flow should be minimal, and extravasation should not be evident. Observing the calf area is important.

If flow is good and extravasation is not evident, connect the intravenous (IV) line with a 3-way stopcock at the needle, and secure the needle with gauze pads and tape.

Although fluid may run from the IV line by gravity, the rate is too slow for resuscitation. Faster rates of infusion occur by drawing up 30-mL to 60-mL aliquots from the intravenous bag and administering manual fluid boluses via the stopcock. Administering medications this way is much easier, as well, and it provides more accurate administration of fluid to small infants. As an alternative for larger boluses, an intravenous pump or pressure bag can be used to increase flow.

Alternative sites for intraosseous (IO) insertion include the distal tibia, distal femur, sternum, and humerus. [3] Alternative sites are used in special situations, such as fractures of the tibia.

The procedure for IO insertion in the distal tibia is as follows:

Palpate the flat portion of distal tibia, just proximal to the medial malleolus. Slightly abduct and externally rotate the hip to expose the site.

Angle the needle 10-15° cephalad to minimize the risk of growth plate injury.

Follow technique as detailed above.

Use of the distal femur for IO insertion is the last resort after failed tibial attempts because landmarks in the distal femur are harder to locate and because overlying tissues are thicker.

The procedure for IO insertion in the distal femur is as follows:

Slightly flex and externally rotate the hip, and flex the knee so that the quadriceps are relaxed.

Insert the needle in the anterior midline, above the external epicondyles, 1-3 cm above the femoral plateau.

Follow technique as detailed above.

The procedure for IO insertion in the proximal humerus is as follows:

Position the patient so the shoulder is adducted and the greater tuberosity is most prominent by lying the patient supine, arm at his or her side, with the palm overlying his or her umbilicus.

Palpate the proximal humerus, and identify the greater tuberosity.

Insert the needle at a 90-degree angle directly into the greater tuberosity.

Follow technique as detailed above

The only absolute contraindication is fracture of the tibia or long bones, which are potential sites for intraosseous (IO) insertion.

Relative contraindications to IO insertion include the following:

Cellulitis overlying the insertion site (Despite the risk of introducing bacteria into the bone or bloodstream, in the absence of other alternatives, cellulitis overlying the selected site does not preclude IO needle placement.)

Inferior vena caval injury (The fluid infused must be able to drain into the central circulation. If this injury is suspected, central venous access superior to the injury is preferred.)

Previous attempt on the same leg bone

Osteogenesis imperfecta because of a higher likelihood of fractures occurring


Intraosseous (IO) access is now considered as one of the recommendations for emergent vascular access in both children and adults. IO devices are currently used for individuals in nontraditional settings, such as patients with burns, patients who experienced trauma, military personnel, and those undergoing simulated chemical and biological disaster training. The spring-loaded, impact-driven devices, which inject needles to a preset depth, have great potential value in mass casualties. [8] Devices that “drill” the IO needle into the bone, such as the EZ-IO shown below (Vidacare, San Antonio, Texas), are also available and demonstrate comparable high success rates and low complication rates. [9, 10, 11, 7]

Leidel BA, Kirchhoff C, Bogner V, Stegmaier J, Mutschler W, Kanz KG, et al. Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Saf Surg. 2009 Oct 8. 3(1):24. [Medline]. [Full Text].

Neuhaus D, Weiss M, Engelhardt T, Henze G, Giest J, Strauss J, et al. Semi-elective intraosseous infusion after failed intravenous access in pediatric anesthesia. Paediatr Anaesth. 2010 Feb. 20(2):168-71. [Medline].

Paxton JH, Knuth TE, Klausner HA. Proximal humerus intraosseous infusion: a preferred emergency venous access. J Trauma. 2009 Sep. 67(3):606-11. [Medline].

Katz DS, Wojtowycz AR. Tibial fracture: a complication of intraosseous infusion. Am J Emerg Med. 1994 Mar. 12(2):258-9. [Medline].

Burke T, Kehl DK. Intraosseous infusion in infants. Case report of a complication. J Bone Joint Surg Am. 1993 Mar. 75(3):428-9. [Medline].

Hansen M, Meckler G, Spiro D, Newgard C. Intraosseous line use, complications, and outcomes among a population-based cohort of children presenting to California hospitals. Pediatr Emerg Care. 2011 Oct. 27(10):928-32. [Medline].

Ngo AS, Oh JJ, Chen Y, Yong D, Ong ME. Intraosseous vascular access in adults using the EZ-IO in an emergency department. Int J Emerg Med. 2009 Aug 11. 2(3):155-60. [Medline]. [Full Text].

Curran A, Sen A. Bone injection gun placement of intraosseous needles. Emergency Medicine Journal. 2005 May. 22(5):366. [Medline].

Frascone RJ, Jensen JP, Kaye K, Salzman JG. Consecutive field trials using two different intraosseous devices. Prehosp Emerg Care. 2007 Apr-Jun. 11(2):164-71. [Medline].

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. [Medline].

Leidel BA, Kirchhoff C, Braunstein V, Bogner V, Biberthaler P, Kanz KG. Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: A prospective, randomized study. Resuscitation. 2010 Apr 29. [Medline].

Babl FE, Vinci RJ, Bauchner H. Pediatric pre-hospital advanced life support care in an urban setting. Pediatr Emerg Care. 2001 Feb. 17(1):5-9. [Medline].

Carley S, Boyd R. Best evidence topic reports. Screw tipped needles for intraosseous access. Emergency Medicine Journal. May 2004. 21(3):336-7. [Medline].

Claudet I, Baunin C, Laporte-Turpin E. Long term effects on tibial growth after intraosseous infusion: A prospective radiographic analysis. Pediatric Emergency Care. 2003. 19(6):397-401. [Medline].

Clem M, Tierney P. Intraosseous infusions via the calcaneus. Resuscitation. 2004. 62(1):107-112. [Medline].

Dogan A, Irmak H, Harman M. Tibial osteomyelitis following intraosseous infusion: a case report. Acta Orthopedica et traumatologica turcica. 2004. 38(5):357-360. [Medline].

Florito BA, Mirza F, Doran TM. Intraosseous access in the setting of pediatric critical care transport. Pediatric Critical Care Medicine. Jan 2005. volume 6 (1):50-53. [Medline].

Guy J, Haley K, Zuspan SJ. Use of intraosseous infusion in the pediatric trauma patient. J Pediatr Surg. 1993 Feb. 28(2):158-61. [Medline].

Henretig FM, King C. Textbook of Pediatric Emergency Procedures. Philadelphia, PA: Lippincott, Williams, and Wilkins; 1997. 289-98.

Hodge D 3rd. Intraosseous infusions: a review. Pediatr Emerg Care. 1985 Dec. 1(4):215-8. [Medline].

La Fleche FR, Slepin MJ, Vargas J. Iatrogenic bilateral tibial fractures after intraosseous infusion attempts in a 3-month-old infant. Ann Emerg Med. 1989 Oct. 18(10):1099-101. [Medline].

Rosetti VA, Thompson BM, Miller J. Intraosseous infusion: an alternative route of pediatric intravascular access. Ann Emerg Med. 1985 Sep. 14(9):885-8. [Medline].

Schwartz SB, Kleid DM. Fictitious fracture after infusion of intravenous contrast material via an intraosseous needle. Pediatric Emergency Care. 2004. 20(12):829-831. [Medline].

Smith R, Davis N, Bouamra O, Lecky F. The utilisation of intraosseous infusion in the resuscitation of paediatric major trauma patients. Injury. 2005 Sep. 36(9):1034-8; discussion 1039. [Medline].

Spivey WH. Intraosseous infusions [published erratum appears in J Pediatr 1987 Dec;111 (6 Pt 1):941]. J Pediatr. 1987 Nov. 111(5):639-43. [Medline].

Vardi A, Berkenstadt H, Levin I. Intraosseous vascular access in the treatment of chemical warfare casualties assessed by advanced simulation: proposed alteration of treatment protocol. Anesthesia and Analgesia. June 2004. 98(6):1753-1758. [Medline].

William Gluckman, DO, MBA, FACEP President and CEO, FastER Urgent Care

William Gluckman, DO, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Association for Physician Leadership

Disclosure: Nothing to disclose.

Rene J Forti, MD Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, Albert Einstein College of Medicine and Children’s Hospital at Montefiore

Rene J Forti, MD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Barry J Evans, MD Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children’s Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children’s Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, Wisconsin Medical Society

Disclosure: Nothing to disclose.

G Patricia Cantwell, MD, FCCM Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami Leonard M Miller School of Medicine/ Holtz Children’s Hospital, Jackson Memorial Medical Center; Medical Director, Palliative Care Team, Holtz Children’s Hospital; Medical Manager, FEMA, South Florida Urban Search and Rescue, Task Force 2

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

Sangeeta Lamba, MD Attending Physician, Section of Emergency Medicine, University Hospital, University of Medicine and Dentistry of New Jersey

Sangeeta Lamba, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Intraosseous Cannulation 

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