Recommendations (2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care) (Circulation, 2010) [MEDLINE]
It is reasonable for providers to establish IO access if IV access is not readily available (Class IIa, LOE C)
Patient with Osteoporosis or Osteogenesis Imperfecta: these patients may have baseline increased risk for bone fractures
Placement in Extremity with a Fracture or Vascular Injury
Placement in an Area with Overlying Infection or Burn
Placement in an Area of Bone Where a Prior Intraosseous Needle Has Been in Place: in this case, fluids/medications may extravasate from the prior intraosseous site into the surrounding tissues
Unsuccessful Intraosseous Insertion May Be Related to Incorrect Landmarks, Pathologically Fragile Bone, Bent Intraosseous Needle, Clogged Intraosseous Needle (by Marrow, Bone Spicules, or Blood Clot), Intraosseous Needle Dislodgement, or Needle Penetration of the Posterior Cortex of the Bone
Time Required for Insertion: 3-120 sec (in most cases)
Comparison of IO with CVC Placement in Patients Undergoing Trauma/Medical Resuscitation in the Emergency Department (Patient Saf Surg, 2009) [MEDLINE]
IO Requires Less Time to Enable Drug/Solution Infusion than Central Venous Catheter Placement
Comparison of BIG Bone Injection Gun Device with EZ-IO Device in Adults in the ED Setting (Resuscitation, 2010) [MEDLINE]
First Attempt Success Rate: 85%
First Attempt Success Rates (Not Statistically Significant): 80% for BIG vs 90% for EZ-IO
Mean Procedure Time: 2 min
Tibial Intraosseous Access (in Out-of-Hospital Cardiac Arrest) was Faster than Peripheral Intravenous Access and Humeral Intraosseous Access (Ann Emerg Med, 2011) [MEDLINE]
Utilization of Intraosseous Device
Pressure Bag or Rapid Infusion Pump is Usually Required to Facilitate Rapid Infusion into the Intraosseous Space
Due to Intraosseous Pressure Being 20-300 mm Hg
Infusion Rate Capability
Intraosseous Needle Can Maintain an Infusion Rate Comparable to a 21-Gauge Peripheral IV
Crystalloid/Blood Product Infusions, Vasopressor Drugs, and Anti-Arrhythmics (Including Amiodarone, etc) Can Be Used Intraosseous
No Drug Dose Adjustment is Required
Intraosseous Medication Delivery
Intraosseus Access Achieves Onset of Action and Drug Concentrations Similar to that Provided by Intravenous Administration
Crystalloid/Blood Product Infusions, Vasopressor Drugs, and Anti-Arrhythmics (Including Amiodarone, etc) Can Be Used
No Drug Dose Adjustment is Required
Drug Delivery to the Central Circulation is Better with Intraosseous Access than with Administration of the Drug Via the Endotracheal Tube
Intraosseous Sample Testing
Blood Gas Analysis, Blood Group Typing, Electrolyte Levels, Drug Levels, and Hemoglobin Levels are Comparable to Those Obtained Intravenously
However, in Patients Who Have Undergone Multiple Fluid/Drug Administrations Via the Intraosseous Needle, Electrolyte and Blood Gas Analysis Values May Subsequently Be Inaccurate: this is especially true for bicarbonate, white blood cell count, and platelet count
Common Commercially Available Intraosseus Access Systems
General Comments
Systematic Review of Intraosseous Devices (Resuscitation, 2012) [MEDLINE]
Only a Few Studies Have Compared Intraosseous Devices (Quality of Evidence is Low): studies suggest that the battery-powered intraosseous driver is superior to manual needles and other semi-automatic intraosseous infusion devices
Bone Injection Gun (BIG) (WaisMed Ltd; Houston, TX)
Approximate Cost: $39 per kit (total cost: $109)
EZ-IO (Vidacare Corp; San Antonio, TX)
Approximate Cost: $200 per kit (total cost: $580)
FAST1 Intraosseous Infusion System (Pyng Medical Corp; Vancouver, BC, Canada)
Approximate Cost: $195 per kit (total cost: $360)
EZ-IO
General Comments
FDA-Approved in 2004: in both adults and children
FDA-Approved Anatomic Insertion Sites
Humeral Head
Medial Tibia (Proximal or Distal): this site may be especially useful during a cardiac arrest, since it is far from the chest, where chest compressions may be ongoing
Inserted needle with EZ-stabilizer dressing in place
Post-Insertion of EZ-IO Needle
Conscious Patient: slow injection of 2 ml of 2% lidocaine (equivalent to 40 mg) over 2 min -> this results in anesthesia of intraosseous space to prevent infusion pain
Unconscious Patient: flush with 10 ml NS -> resistance indicates that IO catheter is in the intraosseus space (lack of resistance indicates that the IO catheter is in the SQ tissue)
EZ-IO Removal
Remove Infusion Connector and EZ-Stabilizer Dressing from IO Needle
Turn IO Needle Clockwise with Pulling Motion: do not bend or rock to avoid separation of the needle from the hub
Adverse Effects/Complications of Intraosseous Vascular Access
General Comments
Overall Complication rate: 1%
Duration of Intraosseous Use: complication rates appear to increase with the duration of use
For This Reason, Intraosseous Needle Use Should Be Limited to Approximately 24 hrs
Epidemiology: microscopic pulmonary emboli are observed in 30% of cases in animal studies (Pediatr Crit Care Med, 2001) [MEDLINE]
Incidence in humans is unclear
Recommendation: since the clinical significance in humans is unclear, intraosseous access should probably be avoided in patients with know right-to-left intracardiac shunts
Rheumatologic/Orthopedic Adverse Effects
Extravasation of Fluids/Medications into the Surrounding Soft Tissue
Intraosseous infusion and pulmonary fat embolism. Pediatr Crit Care Med 2001;2:133–8 [MEDLINE]
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;3(1):24. Epub 2009 Oct 8 [MEDLINE]
Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 suppl 3):S729–S767 [MEDLINE]
A new study of intraosseous blood for laboratory analysis. Arch Pathol Lab Med. 2010;134(9):1253-1260 [MEDLINE]
Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: A prospective, randomized study. Resuscitation. 2010;81(8):994 [MEDLINE]
Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: a randomized controlled trial. Ann Emerg Med. 2011 Dec;58(6):509-16 [MEDLINE]
Current advances in intraosseous infusion – a systematic review. Resuscitation. 2012 Jan;83(1):20-6. doi: 10.1016/j.resuscitation.2011.07.020. Epub 2011 Aug 24 [MEDLINE]
EZ-IO(®) intraosseous device implementation in a pre-hospital emergency service: A prospective study and review of the literature. Resuscitation. 2013 Apr;84(4):440-5. doi: 10.1016/j.resuscitation.2012.11.006. Epub 2012 Nov 14 [MEDLINE]
Vascular access in resuscitation: is there a role for the intraosseous route. Anesthesiology. 2014;120(4):1015-1031 [MEDLINE]
Saving the critically injured trauma patient: a retrospective analysis of 1000 uses of intraosseous access. Emerg Med J. 2015 Jun;32(6):463-7. doi: 10.1136/emermed-2014-203588. Epub 2014 Jun 30 [MEDLINE]
