Please note that all guidance is currently under review and some may be out of date. We recommend that you also refer to more contemporaneous evidence in the interim.
During the first week of life the umbilical vein is a convenient route for obtaining vascular access during emergencies.
The intraosseous (IO) route provides an option for establishing rapid venous access in an emergency after that time.
The bone marrow cavity has an extensive virtually non-collapsible vascular network, which communicates directly with the systemic circulation.
Medications or fluids given by the IO route diffuse a few centimetres through the medullary cavity then enter the venous circulation.
The entry point is a few centimetres below the tibial tuberosity at the centre of the flat antero-medial surface. The needle is directed caudal away from the upper tibial epiphysis in the line of the shaft.
The distal antero-medial surface of the tibia is an alternate site which can be used in children of all ages.
The distal femur and sternum should not be used.
The following equipment is required to perform an intraosseous needle insertion:
- sterile gloves and gown
- basic dressing pack
- antiseptic to prepare the skin
- rigid needle with an inner stylet (for patients < 18 months an 18-20 lumbar puncture needle can be used)
- syringe with NaCl 0.9 per cent flush
- routine IV line tubing set-up and tape.
Watch a demonstration video prepared by the Loma Linda University Medical Centre.
Follow this procedure during an intraosseous needle insertion:
- Observe standard precautions.
- Immobilise the extremity.
- Prepare the site with antiseptic.
- Consider the need to use local anaesthetic (0.5-1 mL 1% lignocaine) if time permits.
- Insert the needle: Hold the needle handle in the palm of the hand while the thumb and forefinger grip the shaft about a centimetre from the point to stabilise the needle.
- Apply firm pressure while using a screwing or rotary action until the bone cortex is traversed.
- Note that at approximately 1 cm or less below the skin surface, a distinct loss of resistance on entry of the bone marrow is felt.
- Blockage of the needle may occur if an inner stylet is not used.
You should notice these three things if the IO needle insertion has been successful:
- A distinctive pop with insertion, or a give or release of resistance is felt.
- The needle flushes without significant subcutaneous infiltration and bone marrow is easily aspirated.
- The needle stands without support.
Once insertion is confirmed: Unscrew and remove the stylet. Attempt bone marrow aspiration (bone marrow can be used as a substitute for venous blood for estimation of PCO2, pH, Hb, electrolytes, urea, creatinine, proteins, etc.). Flush the needle with 5-10 mL of normal saline to decrease the cellularity of the surrounding marrow, aiding subsequent infusions. Attach IV tubing and commence the infusion of medications or fluids by pump.
Recommended intravenous rates for drugs and fluids can be administered via the IO route and reach the central circulation in equivalent times.
Strong alkaline and hypertonic solutions should be diluted before use.
- Osteogenesis imperfecta
- Limb is traumatised
Possible complications of IO needle insertion include:
- Extravasation of fluid, drugs or air into the skin or periosteum through the hole in the bone. A larger hole is created if a rocking motion is used during insertion of the needle. It may also occur if there has been a previous IO infusion in the same bone
- Sub-periosteal infusion may occur when the needle fails to enter the bone marrow
- Through and through puncture occurs if the needle is advanced too far. This carries a risk for compartment syndrome if fluid is infused into a muscle compartment
- Infection (cellulitis, abscess formation, skin necrosis and osteomyelitis)
- Tibial fracture
- Fat and bone marrow microemboli.
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First published: April 2013
Last web update: October 2018
Review by: December 2020
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Page last updated: 24 May 2022