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It can be difficult to obtain venous access in infants and children.
This chapter presents vascular access techniques, including intraosseous
(IO), central venous, and umbilical venous access in the newborn.
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The principle of IO access is that fluids and medications administered into
noncollapsible bone sinuses rapidly enter the central circulation.
Although the IO approach may be used in any age patient, it is particularly amenable
to children as a result of their high percentage of red bone marrow
and relatively thin bony cortex.1,2
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Access to the bone marrow is indicated when there is an emergency
need for vascular access, and other central or peripheral sites
are not easily cannulated. A case series of pediatric resuscitations
demonstrated the mean time to manual IO placement was 4.7 minutes
with a success rate of 83% compared with an average time
to intravascular access of 7.9 minutes.3 More recent
studies using newer devices have demonstrated insertion times of
only seconds with success rates of 94%.4 Various
insertion devices include simple hand-twist needles, hand-held drills,
and spring-loaded devices.
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There are relatively few contraindications to IO placement (Table 32-1), and the reported rate of serious
complications from IO insertion is about 1%.5 By
comparison, central venous catheters have complication rates of at
least 3.4%.6
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Paralytics, anticonvulsants, analgesics, benzodiazepines,
and vasopressors such as epinephrine have comparable infusion IO
and IV infusion rates (Table 32-2).
Blood and blood products can be given by the IO route.7,8
Though pharmacokinetics may differ between IV and IO routes of administration,
any medication or fluid that can be given through an IV can be administered
through an IO. Substances that are toxic to tissues, such as hypertonic
solutions or caustics (e.g., calcium), can cause skin necrosis if
they extravasate into the soft tissues whether from a misplaced
peripheral IV or a misplaced IO needle, and proper positioning of
the catheter or needle should always be checked before administration
of these medications.
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