Intraosseous Access

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Intraosseous vascular access was first introduced by Drinker in 1922 as a method for accessing noncollapsible venous plexuses through the bone marrow cavity to the systemic circulation. With the development of intravenous (IV) catheters, this method was abandoned until the 1980s, when intraosseous access was reintroduced, particularly for rapid fluid infusion during resuscitation. ^[1]

On the basis of previous guidelines, intraosseous access was suggested for children aged 6 years or younger, ^[2]  though subsequent studies have shown that it is safe in older children and adults. ^{[3, 4, 5, 6]}  Successful infusions in newborns have further suggested that access via the intraosseous route is faster than access via umbilical veins. ^{[7, 8]}

The Emergency Cardiovascular Care Guidelines of 2000 recommended intraosseous access in all children after two failed attempts at IV access or during circulatory collapse. In 2010, the American Heart Association recommended intraosseous access if venous access cannot be quickly and reliably established. ^[9]

Intraosseous access may be easily established by users with little training and is more rapidly achieved than IV access. ^[10]  Manual insertion with force had previously been the primary method for intraosseous insertion, but automated intraosseous insertion devices such as the Arrow EZ-IO (Teleflex, Morrisville, NC) ^[11]  have been growing in popularity. ^[12]  Studies have suggested that these automated devices are safe and highly successful on first attempts in both children and adults. ^{[13, 14, 15, 16]}

Several articles have described the use of intraosseous access in military and rescue scenarios, where rapid access may be crucial, peripheral venous access may be hard to obtain, and first responders may have limited experience or technical capacity. ^{[17, 18, 19, 20]}

Blood obtained through intraosseous access may be used to obtain most laboratory values, including pH level, carbon dioxide tension (PCO₂), and ABO and Rh typing. ^[21]  The results of these standard laboratory tests may differ slightly from results obtained with venous blood samples because of low flow and stasis in the bone marrow. All medications and blood products can be safely administered through the intraosseous line, and the onset of action and peak drug levels are comparable to those of IV administration.

Intraosseous access has also been employed for injection of contrast media in computed tomography (CT) angiography. ^[22]

Intraosseous needles left in the marrow for longer than 72 hours are at a higher risk of local infection; thus, needles should be removed as soon as permanent venous access is established.

One indication for intraosseous access is difficulty in establishing venous access, as in the following settings:

Another is a condition necessitating rapid high-volume fluid infusion, such as the following:

Another is to afford access to the systemic venous circulation, as with the following:

Contraindications for intraosseous access include the following:

Burgert JM. A primer on intraosseous access: History, clinical considerations, and current devices. Am J Disaster Med. 2016 Summer. 11 (3):167-173. [Medline].

Smith R, Davis N, Bouamra O, Lecky F. The utilisation of intraosseous infusion in the resuscitation of paediatric major trauma patients. Injury. 2005 Sep. 36(9):1034-8; discussion 1039. [Medline].

Atkins DL, Chameides L, Fallat ME, et al. Resuscitation science of pediatrics. Ann Emerg Med. 2001 Apr. 37(4 Suppl):S41-8. [Medline].

Waisman M, Waisman D. Bone marrow infusion in adults. J Trauma. 1997 Feb. 42(2):288-93. [Medline].

Lowther A. Intraosseous access and adults in the emergency department. Nurs Stand. 2011 Aug 3-9. 25(48):35-8. [Medline].

Leidel BA, Kirchhoff C, Bogner V, Braunstein V, Biberthaler P, Kanz KG. Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins. Resuscitation. 2012 Jan. 83 (1):40-5. [Medline].

Ellemunter H, Simma B, Trawöger R, Maurer H. Intraosseous lines in preterm and full term neonates. Arch Dis Child Fetal Neonatal Ed. 1999 Jan. 80(1):F74-5. [Medline].

Hansen M, Meckler G, Spiro D, Newgard C. Intraosseous line use, complications, and outcomes among a population-based cohort of children presenting to california hospitals. Pediatr Emerg Care. 2011 Oct. 27(10):928-32. [Medline].

[Guideline] Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, et al. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2. 122 (18 Suppl 3):S876-908. [Medline]. [Full Text].

Abe KK, Blum GT, Yamamoto LG. Intraosseous is faster and easier than umbilical venous catheterization in newborn emergency vascular access models. Am J Emerg Med. 2000 Mar. 18(2):126-9. [Medline].

Cooper BR, Mahoney PF, Hodgetts TJ, Mellor A. Intra-osseous access (EZ-IO) for resuscitation: UK military combat experience. J R Army Med Corps. 2007 Dec. 153(4):314-6. [Medline].

Brenner T, Bernhard M, Helm M, Doll S, Völkl A, Ganion N, et al. Comparison of two intraosseous infusion systems for adult emergency medical use. Resuscitation. 2008 Sep. 78(3):314-9. [Medline].

Horton MA, Beamer C. Powered intraosseous insertion provides safe and effective vascular access for pediatric emergency patients. Pediatr Emerg Care. 2008 Jun. 24(6):347-50. [Medline].

Schwartz D, Amir L, Dichter R, Figenberg Z. The use of a powered device for intraosseous drug and fluid administration in a national EMS: a 4-year experience. J Trauma. 2008 Mar. 64 (3):650-4; discussion 654-5. [Medline].

Wampler D, Schwartz D, Shumaker J, Bolleter S, Beckett R, Manifold C. Paramedics successfully perform humeral EZ-IO intraosseous access in adult out-of-hospital cardiac arrest patients. Am J Emerg Med. 2012 Sep. 30 (7):1095-9. [Medline].

Schalk R, Schweigkofler U, Lotz G, Zacharowski K, Latasch L, Byhahn C. Efficacy of the EZ-IO® needle driver for out-of-hospital intraosseous access – a preliminary, observational, multicenter study. Scand J Trauma Resusc Emerg Med. 2011 Oct 26. 19:65. [Medline]. [Full Text].

Rush S, D’Amore J, Boccio E. A review of the evolution of intraosseous access in tactical settings and a feasibility study of a human cadaver model for a humeral head approach. Mil Med. 2014 Aug. 179(8 Suppl):24-8. [Medline].

Lewis P, Wright C. Saving the critically injured trauma patient: a retrospective analysis of 1000 uses of intraosseous access. Emerg Med J. 2015 Jun. 32 (6):463-7. [Medline].

Vassallo J, Horne S, Smith JE. Intraosseous access in the military operational setting. J R Nav Med Serv. 2014. 100 (1):34-7. [Medline].

Helm M, Haunstein B, Schlechtriemen T, Ruppert M, Lampl L, Gäßler M. EZ-IO(®) intraosseous device implementation in German Helicopter Emergency Medical Service. Resuscitation. 2015 Mar. 88:43-7. [Medline].

Evans RJ, Jewkes F, Owen G, McCabe M, Palmer D. Intraosseous infusion–a technique available for intravascular administration of drugs and fluids in the child with burns. Burns. 1995 Nov. 21(7):552-3. [Medline].

Winkler M, Talley C, Woodward C, Kingsbury A, Appiah F, Elbelasi H, et al. The use of intraosseous needles for injection of contrast media for computed tomographic angiography of the thoracic aorta. J Cardiovasc Comput Tomogr. 2017 Mar 16. [Medline].

Clemency B, Tanaka K, May P, Innes J, Zagroba S, Blaszak J, et al. Intravenous vs. intraosseous access and return of spontaneous circulation during out of hospital cardiac arrest. Am J Emerg Med. 2017 Feb. 35 (2):222-226. [Medline].

Clinical education resources: Arrow EZ-IO Intraosseous Vascular Access System. Teleflex. Available at http://www.teleflex.com/en/usa/ezioeducation/index.html. 2017; Accessed: March 29, 2017.

Shina A, Baruch EN, Shlaifer A, Shovali A, Levi M, Yosefy O, et al. Comparison of Two Intraosseous Devices: The NIO Versus the EZ-IO by Novice Users-A Randomized Cross Over Trial. Prehosp Emerg Care. 2016 Nov 21. 1-7. [Medline].

Demir OF, Aydin K, Akay H, Erbil B, Karcioglu O, Gulalp B. Comparison of two intraosseous devices in adult patients in the emergency setting: a pilot study. Eur J Emerg Med. 2016 Apr. 23 (2):137-42. [Medline].

FAST1 Sternal IO. Pyng Medical. Available at http://www.pyng.com/fast1/. 2017; Accessed: March 29, 2017.

Introducing the NIO. PerSys Medical. Available at http://www.nio-pm.com/. Accessed: March 29, 2017.

Bone Injection Gun – adult. PerSys Medical. Available at http://ps-med.com/products/vascular/BIG-A. Accessed: March 29, 2017.

Fiallos M, Kissoon N, Abdelmoneim T, et al. Fat embolism with the use of intraosseous infusion during cardiopulmonary resuscitation. Am J Med Sci. 1997 Aug. 314(2):73-9. [Medline].

Brickman KR, Rega P, Schoolfield L, Harkins K, Weisbrode SE, Reynolds G. Investigation of bone developmental and histopathologic changes from intraosseous infusion. Ann Emerg Med. 1996 Oct. 28(4):430-5. [Medline].

Ee Tein Tay, MD Assistant Professor of Emergency Medicine and Pediatrics, Mount Sinai Medical Center

Ee Tein Tay, MD is a member of the following medical societies: American Academy of Pediatrics, American Institute of Ultrasound in Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Waseem Hafeez, MBBS Associate Professor of Clinical Pediatrics, Albert Einstein College of Medicine; Attending Physician, Division of Pediatric Emergency Medicine, Children’s Hospital at Montefiore, New York

Waseem Hafeez, MBBS is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Surgical Association, Pacific Coast Surgical Association, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Western Vascular Society

Disclosure: Nothing to disclose.

Andrew K Chang, MD, MS Vincent P Verdile, MD, Endowed Chair in Emergency Medicine, Professor of Emergency Medicine, Vice Chair of Research and Academic Affairs, Albany Medical College; Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Emergency Medicine, Montefiore Medical Center

Andrew K Chang, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American Academy of Pain Medicine, American College of Emergency Physicians, American Geriatrics Society, American Pain Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the assistance of Lars J Grimm, MD, MHS, with the literature review and referencing for this article.

Intraosseous Access

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