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

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
https://www.youtube.com/watch?v=KHXSfh2ZRDM

Related articles

 * Infusion
 * Cardiopulmonary resuscitation of the newborn