Back to Basics: Intraosseous Lines
Back to Basics: Intraosseous Lines
Author: Rahul Gupta, MD
• Indications
• Failure to gain IV access in critical patient (burns, shock, resuscitation)
• Temporizing measure to allow stabilization and to facilitate long-term IV access
• Contraindications
• Fractured at or proximal to site or previously penetrated
• Vascular interruption
• cellulitis overlying skin
• Bone disease (OI, osteoporosis)
• Complications:
• Long-term use - >24 hours associated with osteomyelitis
• Fracture, extravasation, compartment syndrome
• Insertion Site:
• Proximal tibia (2 finger widths below tibial tuberosity)
• Distal femur
• Distal tibia/fibula
• Proximal humerus - arguably the best due to highest flow rate, but may interfere with resuscitations activities
• Sternum - best if all limbs are injured
• Anterior superior iliac spine: best in soft boned pediatric patients
• Sizes
• 15 mm - pink (3-39kg person), 25 mm - blue (>40kg person), 45 mm - yellow (>40kg with lots of subcutaneous tissue)
• Yellow is the color of fat
• Pink is exclusively Peds
• Confirmation of Line
• Achieved with aspiration of bone marrow, flushing needle without evidence of extravasation, and clear visualization of needle standing firmly in bone
• Fluid Infusion
• Can infuse IV drug or fluid (same dose); flush with 20 mL saline flush
• Rate: sternum > proximal humerus > tibia
• Labs
• Accurate: Hgb/Hct, pH, pCO2, Bicarb, chloride, BUN, creatinine, glucose, serum drug levels, cultures, albumin
• Inaccurate: WBC, Potassium, Ionized Ca, AST/ALT, Blood oxygenation
References:
2. Mittiga MR, Ruddy RM. Procedures. In: Shaw KN, Bachur RG, eds. Fleisher & Ludwig’s Textbook of Pediatric Emergency Medicine. 7th ed. Philadelphia, PA: Wolters Kluwer; 2016:(Ch) 141.
4. Leidel, B.A., Kirchhoff, C., Bogner, V., Stegmaier, J., Mutschler, W., Kanz, KG., & Braunstein, V. (2009). Is the intraosseous 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 Safety in Surgery, 3(1), 24-31. doi: 10.1186/1754-9493-3-24