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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 arrest.1,2

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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

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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

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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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