Obtaining peripheral vascular access in the critically ill pediatric
patient may be difficult and time-consuming. It may be difficult
because of the small size of the peripheral veins, the increased subcutaneous
tissue, and vascular collapse that may accompany severe dehydration
or cardiac arrest. Administration of endotracheal medications may
not provide rapid and reliable drug absorption during a cardiorespiratory
An alternative route for blood, drug, and fluid administration
is via an intraosseous line. This previously abandoned technique
was reintroduced in the mid-1980s in response to the need for more immediate
vascular access during cardiopulmonary resuscitation.3,4 Studies
have demonstrated that peripheral venous access during pediatric
cardiac arrest constituted the fastest way of obtaining vascular
access (mean time of 3.0 minutes). However, it was only successful
in 17 percent of patients. This was in stark contrast to the 83
percent success rate for intraosseous lines, 81 percent for peripheral
venous cutdowns, and 77 percent for central venous lines.5,6 The time
required to place an intraosseous line was 4.7 minutes
compared to 8.4 minutes for a central venous line and 12.7 minutes
for a peripheral venous cutdown. The insertion of an intraosseous
line was recently studied in the prehospital arena, where it was
shown to be safe and effective.7,8 Intraosseous infusion
is quick, safe, and effective in compromised neonates.9 There
has also been interest in its role in the resuscitation of adult
patients when vascular access is unobtainable.10
Long bones are composed of a dense outer cortex and inner soft,
spongy (cancellous) bone (Figure 44-1). The nutrient artery supplies
the bone with a rich vascular network. It pierces the cortex and
divides into ascending and descending branches that further divide
into arterioles and then capillaries. Venous drainage from the capillaries
into the medullary venous sinusoids, located at the proximal and
distal portions of the long bone, flows into the central venous
channel located in the shaft of the long bone.11
Venous anatomy of a long bone.
The intraosseous needle is inserted through the cortex and into
the bone marrow (medullary) cavity of a long bone. Numerous anatomic
sites can be used to access the medullary cavity. The most traditional
site, which is favored in pediatric patients, is the flat anteromedial
surface of the proximal tibia (Figure 44-2). The distal tibia just
above the medial malleolus is the preferred site in adult patients
(Figure 44-3). In the adult, it is easier to penetrate the cortex
of the medial malleolus than the thicker cortex of the proximal
tibia. A third site for intraosseous access is the flat anterior surface
of the distal femur (Figure 44-4).
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