Intraosseous infusion

Intraosseous infusion in cases where it is necessary to ensure access to the bloodstreamn which cannot be ensured even with a line. All drugs, including solutions and blood derivatives, can be administered intraosseously. The speed of onset of action is comparable to central venous access. It is most often used in pre-hospital care, in hospitals it can help in urgent situations, especially if it is not possible to cannulate the central vein reliably and quickly.

A certain disadvantage is the painful application, the need for special cannulae and the limited time of possible use - 6-12, exceptionally a maximum of 24 hours of use are mentioned. The pain during bone penetration is overestimated, it is comparable or less than skin puncture with a wider cannula (Gronych 2014).

Indication

• impossibility of inserting an intravenous cannula (two unsuccessful attempts in an emergency situation)
• cardiopulmonary resuscitation
• shock of any etiology
• status epilepticus

Intraosseous Infusion

Contraindications

• osteogenesis imperfecta
• osteopetrosis
• fractura tibiae or other bones chosen for puncture
• patient refusal
• injection site infection, previous orthopedic surgery
• intra-abdominal and pelvic injuries from intended bony entry in the inferior vena cava basin

Approches

• humeral head (suitable for resuscitation)
• proximal part of the tibia at the site of tuberositas tibiae (children < 6 years)
• distal femur
• calcaneus (newborns and children < 6 months)

Proximal tibial procedure

• the patient is in the supine position
• We support the slightly bent lower limb so that the lower leg rests on a firm base (i.e. to ensure good stabilization of the lower leg)
• the injection site is the proximal part of the tibia, approximately 2 cm medial and 2 cm proximal (distal in children) from the tuberositas tibiae , strict aseptic conditions must be ensured during the procedure
• perpendicular to the long axis of the bone, we penetrate the bone matrix and penetrate the bone marrow with a helical movement (penetration into it is associated with a loss of resistance), the depth of injection is usually 1-1.5 cm

After introducing

• the needle is in the correct position when it rests firmly in the bone and when we aspirate the marrow
• in a conscious patient, we very slowly apply 2 ml of local anesthetic
• if we think we are in the right position, but the bone marrow cannot be aspirated, we flush the needle with 10 ml (children 2-5 ml) of physiological solution and observe whether there is an arching
• first bolus forcefully within 5 sec loosening of trabecular bone (No flush = no flow)
• if everything is without problems, fix the needle and cover it sterilely

Complications

• superficial infections
• osteomyelitis
• subperiosteal infusion
• compartment syndrome
• transient appearance of blasts in peripheral blood
• needle dislocation and subsequent bleeding
• according to some authors, fat embolism in adult patients
• damage to growth cartilage in children

Video

<mediaplayer width='500' height='300'>https://www.youtube.com/watch?v=KHXSfh2ZRDM</mediaplayer>

Links

References

• ŠEVČÍK, Pavel, et al. Intenzivní medicína. 3. edition. Galén, 2014. 1195 pp. pp. 100. ISBN 9788074920660.

• HAVRÁNEK, Jiří: Intraoseální infuze. (upraveno)
• Gronych, Luděk 2014
• Leták výrobce pro lokalizaci návrtu na humeru
• Kubalová, Jana 2017

Related articles

• Infusion
• Cardiopulmonary resuscitation of the newborn