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Obtaining peripheral vascular access in the critically ill patient may be difficult and time-consuming. The vascular collapse that may accompany severe dehydration or a cardiac arrest can be profound and delay administration of essential therapies. Pediatric patients, in particular, may present a challenge due to the small size of their peripheral veins and the increased subcutaneous tissue. Administration of endotracheal medications may not provide rapid and reliable drug absorption during a cardiorespiratory arrest.1,2

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Intraosseous (IO) access was first described in 1922 by Dr. Drinker. He referred to the medullary cavity as a “non-collapsible vein” that can be used for obtaining rapid vascular access. IO access for pediatric use was introduced in 1941. The first IO blood transfusion was documented in1942. The IO route of venous access did not become popular for many reasons. The equipment at the time was crude and did not improve until the 1970s. The technique of a saphenous venous cutdown was soon developed as an alternative method for obtaining vascular access. The development of plastic, disposable, and single use intravenous (IV) catheters revolutionized the technique of IV access.

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IO access is an alternative route for blood, drug, and fluid administration. 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 This procedure has focused on pediatric patients due to the increased difficulty and necessity of access in critically ill children. Studies have demonstrated that peripheral venous access during pediatric cardiac arrest constituted the most expeditious manner of obtaining vascular access (mean time of 3.0 minutes). However, it was only successful in 17% of patients. This was in stark contrast to the 83% success rate for IO lines, 81% for peripheral venous cutdowns, and 77% for central venous lines.5,6 The time required to place an IO 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 IO line was recently studied in the prehospital arena, where it was shown to be safe and effective.7,8 IO infusion is also quick, safe, and effective in compromised neonates.9

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IO access has been increasingly used in the resuscitation of adult patients when vascular access is unobtainable.10,11 For prehospital providers, IO access has proved to be an invaluable procedure. One national prehospital study noted success rates for IO placement at 91%, with the majority of patients being adults.12 In adults over the age of 80 years, success rates neared 97%. The newer powered devices make penetrating the adult cortical bone much less difficult.12

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Long bones are composed of a dense outer cortex and inner soft, spongy (cancellous) bone (Figure 55-1). The nutrient artery supplies the bone with a rich vascular network. It pierces the cortex and divides into ascending and ...

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