Chapter 70: Intraosseous Infusion

INTRODUCTION

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 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 Establishing vascular access quickly in these cases can be lifesaving.

Intraosseous (IO) access was first described in 1922 by Dr. Drinker. He referred to the medullary cavity as a “noncollapsible vein” that can be used for obtaining rapid vascular access. IO access for pediatric use was introduced in 1941, and the first IO blood transfusion was documented in 1942.³ The IO route of venous access did not enjoy widespread use for several reasons. The equipment for performing an IO at the time was crude and did not improve until the 1970s. The saphenous venous cutdown technique was developed and gained popularity as an alternative method for obtaining vascular access when attempts at peripheral vein cannulation failed. Finally, the development of plastic, disposable, and single-use intravenous (IV) catheters revolutionized the technique of IV access and made this modality the preferred primary method.

IO access experienced a resurgence in popularity in the mid-1980s as its utility in the care of the critically ill patient was increasingly recognized.^4,5 IO access may be used to administer blood products, drugs, and fluids during cardiopulmonary resuscitation, a scenario where peripheral IV access may be particularly challenging. This procedure was more widely deployed in the care of pediatric patients due to the increased difficulty of obtaining vascular access in profoundly ill children. The IO placement time was slightly longer in pediatric cardiac arrest than peripheral venous access (3.0 versus 4.7 minutes), but the IO success rate was significantly higher (83% versus 17%).⁶ IO infusion has been shown to be safe and effective in neonates and may be more rapidly obtainable than umbilical venous catheters.^7,8 The use of IO devices in pediatric patients has become widespread, associated with high success rates, and associated with a low incidence of complications.^7-9 IO access will cause metal artifact in most cases if obtaining a computed tomography (CT) scan of the area.¹⁰

IO access has been increasingly used in the resuscitation of adult patients when vascular access is unobtainable. It has become the first-line option for cardiac arrest patients.^11-14 IO access has become an invaluable procedure for prehospital providers and has repeatedly been shown to be safe and effective.^14-17 The newer commercially available powered devices make penetrating the adult bone cortex much less difficult. Several prehospital studies have demonstrated success rates for IO placement of ≥ 90%.^17,18 Emergency Medical Services systems have integrated IO devices ...