Intraosseous Vascular Access

Core Standard

Clinicians must evaluate patients and anticipate appropriate use of the intraosseous (IO) route when difficult vascular access is expected or encountered. This applies to emergent, urgent, and medically necessary situations where timely vascular access is critical to patient outcomes.

1. Indications for Intraosseous Access

1.1 Cardiac Arrest

The IO route should be utilized in cardiac arrest when intravenous (IV) access is unavailable or cannot be promptly established.

Pediatric Considerations: Advanced life support guidelines for pediatric patients recommend the IO route as an initial vascular access option during cardiac arrest, or when IV access cannot be obtained within 30 seconds.

Neonatal Considerations: Umbilical access remains the preferred route for neonatal resuscitation. However, IO access may be considered when IV access is not feasible. Evidence guiding IO utilization in neonatal resuscitation remains limited, resulting in underutilization. Recent animal studies have demonstrated similar survival outcomes when comparing IO versus IV epinephrine delivery, suggesting IO may be a viable alternative when umbilical access is delayed or unavailable.

1.2 First-Attempt Success and Efficiency

IO access demonstrates high first-attempt insertion success rates with low complication rates and reduced overall vascular access attempts compared to repeated peripheral IV attempts.

1.3 Transition to Venous Access

If patient status does not improve with IO use, clinicians should escalate to a venous access option. Prompt escalation facilitates rapid delivery of resuscitation medications and solutions.

1.4 Comparative Outcomes: IO Versus IV Delivery

The clinical impact of IO delivery compared to IV delivery (peripheral or central) on patient outcomes requires further investigation.

Multiple factors influence patient outcomes such as return of spontaneous circulation (ROSC), survival to discharge, and length of stay. Current evidence yields indeterminate recommendations due to several complicating factors:

Research Limitations: The body of literature suffers from heterogeneous and retrospective methodology, limiting the ability to determine the impact of IO versus venous delivery. High-quality prospective research is needed to establish pharmacokinetic properties from various IO sites, measure the impact of “time to intervention,” and evaluate outcomes in critically ill patients.

Selection Bias: IO access is preferentially used in high-acuity patients who inherently carry higher risk of negative outcomes, confounding outcome comparisons.

Underutilization: The IO route remains underutilized due to insufficient training and equipment availability.

Access Delays: Transition to IO often occurs only after multiple unsuccessful IV attempts, during which patient condition may deteriorate.

Documentation Gaps: Many clinical settings lack adequate documentation of IO site selection or prior IV attempts.

Flow Rate Variables: Several factors may reduce flow rates during IO use, including viscosity of the infusate, add-on devices, anatomic resistance in the medullary space, needle malposition, and distal IO sites such as the distal tibia.

Absorption Variables: Bone perfusion and medication absorption are influenced by hypoperfusion states, hypovolemia, catecholamine effects on red marrow, and lipid binding within the medullary space.

2. Emergent and Non-Emergent Clinical Applications

The IO route should be considered for patients with limited or no vascular access, or when delayed access may increase morbidity or mortality risk.

2.1 Established Clinical Applications

IO access has been successfully utilized in numerous clinical scenarios including: hemorrhagic shock, septic shock, life-threatening seizures and status epilepticus, extensive burns, traumatic injuries, transfusion therapy, severe dehydration, anesthesia administration, rapid sequence intubation, hypertonic saline administration for acute intracranial hypertension, palliative and end-of-life care, and radiologic imaging with radiologic confirmation of placement prior to contrast administration.

Clinicians should consult manufacturer instructions for use to verify appropriateness of IO use in specific clinical situations.

Lipid Emulsion Caution: Exercise caution with IO delivery of injectable lipid emulsion. Case reports describe delayed improvement in patient outcomes when using this route.

Pediatric Septic Shock: A prospective interventional randomized clinical trial demonstrated that IO insertion for resuscitation of pediatric patients with septic shock was associated with significantly shorter time to vascular access, reduced length of stay, and decreased mortality compared to peripheral IV access.

2.2 Blood Product Administration

Recent studies report low incidence of complications with IO administration of blood products. Research indicates successful delivery of whole blood, freeze-dried plasma, and warm fresh whole blood (WFWB) in trauma settings. Secondary IO insertion may be required in polytrauma situations. Further research in this area is warranted.

3. Contraindications

3.1 Absolute Contraindications

The following anatomic and clinical conditions preclude IO insertion at the affected site:

Compartment syndrome in the target extremity represents an absolute contraindication due to risk of worsening the condition. A previously used IO site or recent failed IO attempt at the same location should not be reattempted. Fractures at or proximal to the intended insertion site compromise the ability to achieve adequate placement and medication delivery. Previous orthopedic surgery or hardware at the site interferes with needle placement and drug distribution. Active infection or severe burns near the insertion site increase infection risk and compromise tissue integrity. Local vascular compromise limits the effectiveness of IO infusion. History of sternotomy contraindicates sternal IO placement.

3.2 Relative Contraindications

Bone diseases such as osteogenesis imperfecta and osteoporosis increase the risk of iatrogenic fracture and should prompt consideration of alternative sites or access methods.

4. Education and Competency Requirements

Appropriate use of IO access is improved through comprehensive education and competency programs. Underutilization of the IO route across multiple clinical settings has been consistently documented.

4.1 Competency Program Components

Training programs should include initial and ongoing validation of safe insertion knowledge and skills through demonstration, demonstration of appropriate device management, and the ability to recognize complications related to IO access and removal.

4.2 Simulation Training Considerations

Training should incorporate simulated challenging clinical situations, including scenarios involving biohazardous exposure and nighttime or low-light conditions. Appropriate personal protective equipment (PPE) and supplies should be utilized during training.

Research conducted during the COVID-19 pandemic comparing IO and peripheral IV catheter (PIVC) access while wearing full PPE indicates that PPE impacts dexterity and procedure completion time. Notably, time to successful IO insertion was reduced compared to PIVC insertion when providers wore full PPE, suggesting IO may be advantageous in contaminated environments.

For nighttime insertion scenarios, tactical headlamps have been found superior to night vision goggles for IO insertion accuracy.

5. Device Selection

5.1 General Considerations

Device selection should be appropriate for the patient’s age and clinical condition. Performance metrics including success rates, time to placement, ease of use, and user preference vary based on training and individual experience. Current evidence does not establish clear superiority of one device over another.

5.2 Neonatal Considerations

A three-arm randomized clinical simulation study in neonates found that manual IO needles demonstrated higher rates of successful insertion compared to powered IO drills.

5.3 Safety Engineering

Consider using safety-engineered IO devices to reduce needlestick injury risk.

6. Site Selection and Needle Sizing

Site and needle selection should be based on the clinical situation and manufacturer directions for use. Current needle size recommendations are weight- and age-based.

6.1 Needle Length Adjustment

Needle length should be adjusted for the thickness of skin overlying the IO insertion site, particularly in children and adults with higher body mass index (BMI). Pretibial subcutaneous skin thickness correlates most strongly with BMI, necessitating longer needles in patients with elevated BMI.

6.2 Common Insertion Sites

The sites most commonly reported in the literature for both adults and children include the proximal tibia, distal tibia, proximal humerus, distal femur, and the sternum (adults only).

6.3 Alternative Sites

Less commonly reported sites include the medial surface of the ankle, radius, ulna, iliac crest, and clavicle. These alternative sites may be necessary due to traumatic injury or amputations.

Sternal Site Considerations: The sternal insertion site is approved by the U.S. Food and Drug Administration (FDA) for patients aged 12 years and older due to risk of injury to retrosternal structures in younger patients. The sternal site has been used successfully during chest compressions and offers several advantages in specific clinical situations: increased flow rates with gravity flow possible, lower bone density and minimal overlying skin facilitating easier insertion, readily visible location, direct access to central circulation, and presence of red marrow to improve absorption.

Proximal Tibial Optimization: A radioanatomical study determined the optimal adult proximal tibial IO insertion site to be 0.5 cm below the tibial tuberosity at the midline of the medial surface, with the standard needle length noted to be 17 mm.

Neonatal Alternative Sites: Cadaveric study of neonates suggests that the proximal humerus and distal femur may be considered as IO insertion options when primary sites are unavailable.

6.4 Landmark Identification

Proper landmarks must be identified prior to insertion to avoid complications related to improper placement. Ultrasound visualization improves landmark identification accuracy.

Ultrasound has proven reliable for identifying proximal humerus landmarks across patients of various BMIs.

Obesity is identified as a common factor for insertion failure due to difficulty identifying anatomic landmarks.

7. Pain Management

7.1 Pre-Insertion Anesthesia

Consider subcutaneous lidocaine administration as local anesthesia prior to insertion at the intended site when patient condition and clinical urgency permit.

7.2 Infusion-Related Pain

For pain associated with IO infusion, consider slow IO administration of 2% preservative-free and epinephrine-free lidocaine prior to infusion initiation.

8. Aseptic Technique

Strict aseptic non-touch technique should be maintained during IO placement and infusion. Given the complexity of IO device placement, the use of sterile gloves should be considered.

8.1 Skin Antisepsis

Skin antisepsis should be performed using an appropriate solution such as alcohol-based chlorhexidine, povidone-iodine, or 70% alcohol, based on organizational policies and procedures. Current evidence does not identify an optimal antiseptic solution specifically for IO insertion.

9. Placement Confirmation

Correct IO device placement should be confirmed through assessment of the following indicators: correct needle position, sensation of loss of resistance upon bone penetration, and absence of signs of infiltration upon flushing with preservative-free 0.9% sodium chloride (5–10 mL for adults; 2–5 mL for pediatric patients).

Aspiration of blood or bone marrow assists in confirmation but may be difficult in certain patients, such as those with severe dehydration. Inability to aspirate should not alone be interpreted as improper placement if other confirmation indicators are present.

9.1 Ultrasound Confirmation

Color Doppler ultrasound may be considered to confirm initial and ongoing placement.

10. Laboratory Analysis from IO Aspirate

10.1 General Guidance

The initial IO aspirate may be reserved for laboratory analysis when no other sampling options exist. However, caution is warranted in interpreting laboratory results from IO aspirate, as IO blood samples demonstrate inconsistent correlation with venous and arterial samples in critically ill patients.

10.2 Point-of-Care Testing Accuracy

IO aspirate point-of-care testing has demonstrated accuracy for glucose, calcium, sodium, pH, and bicarbonate measurements. Potassium levels drawn from IO samples may overestimate serum levels but remain useful for ruling out hyperkalemia.

10.3 Blood Typing and Coagulation Studies

IO blood sampling may provide accurate results for blood typing. However, IO aspirate should not be used for rotational thromboelastometry (ROTEM) in trauma care due to increased coagulation effects.

10.4 Research Limitations

The majority of blood sampling research has been conducted on healthy subjects. Further research is needed to establish reference values for IO laboratory measurements and improve the validity of laboratory analysis from IO aspirate in critically ill patients.

11. Dressing and Securement

A sterile dressing should be applied over the IO access site and the device must be properly secured.

11.1 Transport Considerations

Securement integrity should be verified prior to patient transport to prevent dislodgement.

12. Infusion Delivery Methods

An external pressure device (300 mm Hg) or infusion pump should be used for consistent solution and medication delivery. While IO infusion may be successfully administered via gravity, significant variability in flow rates has been demonstrated based on the specific device and insertion site.

13. Complication Monitoring

13.1 Overview of Complications

While the rate of immediate complications associated with IO access is very low, data regarding long-term complications remains limited. Potential IO-related complications include: infiltration and extravasation (into surrounding tissue and intra-articular spaces), compartment syndrome, iatrogenic bony fracture, site infection, osteomyelitis, fat embolism, air embolism, and traumatic bullae.

13.2 Infiltration and Extravasation Prevention

Risk of infiltration and extravasation can be reduced through the following measures: avoiding multiple attempts at the same site, ensuring proper needle placement with a straight perpendicular path, properly securing the IO device, monitoring flow and detecting flow loss, immobilizing the involved extremity when necessary, validating IO placement and patency during patient transport or repositioning, confirming placement before infusing highly irritating solutions or known vesicants, performing ongoing assessment of the IO site and extremity including palpation and calf circumference measurement for tibial placement, and limiting infusion time to less than 24 hours.

Pediatric Risk: Infants and young children may be at greater risk for extravasation and subsequent compartment syndrome due to small bone size and potentially inappropriate needle length. A postmortem study of infants after IO insertion noted a 53% failure rate (nonmedullary placement) in infants 6 months and younger.

13.3 Treatment of Complications

Patients should be observed and promptly treated for IO-related complications. Infectious complications are more likely to occur with prolonged infusion duration or if bacteremia was present at the time of insertion. Risk of IO-related fat emboli may be increased with rapidly repeated infusions or high flow rates.

13.4 Delayed Presentation

IO-related complications may present in a delayed fashion. Accurate documentation of IO insertion details (including location and failed attempts), duration of use, and removal is critical for proper identification of IO-related complications such as infection, fracture, or nerve injury.

14. Device Removal

The IO device should be promptly removed within 24 hours, when therapy is complete, or if signs of dysfunction occur.

14.1 Extended Dwell Time

Dwell time for specific devices may be extended (not to exceed 48 hours total) in instances where alternative vascular access cannot be successfully established. Manufacturer directions for use should be followed for both extended use and device removal to reduce complication risk.

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