Intraosseous Insertion Gwen Hollaar University of Calgary.
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Transcript of Intraosseous Insertion Gwen Hollaar University of Calgary.
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Intraosseous Insertion
Gwen Hollaar
University of Calgary
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Outline
• How does it work
• Indications and Contraindications
• Technique
• Complications
• Review
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How Does It Work
• Bone has two components– Bone cortex– Bone marrow
• Bone marrow contains– Developing blood cells– Framework for vascular complex of the
medulla• Provides blood supply for bone
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How Does It Work
• Path of fluids into body blood vessels• Fluid enters venous sinusoids in medullary
cavity• Fluid drains into central venous channel• Fluid exits bone cortex through nutrient veins
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How Does It Work• Intraosseous (IO) infusion
– Can deliver fluids as quickly as IV method– Can administer drugs and blood through IO
infusion• Onset and peak drug levels are similar
to IV administration
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Indications and Contraindications
• Indications– EMERGENCY VASCULAR ACCESS when
usual methods have failed– Initially recommended in children < 6 years– Now also recognized as useful
resuscitation technique for adults
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Indications and Contraindications
• Absolute Contraindication– Fracture near access site
• Relative Contraindications– Cellulitis over insertion site– Bacteremia– Osteoporosis
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Technique
• Sterile Procedure• Equipment
– Sterile gloves– Drape– Alcohol or cleaning solution– IO needle holder– 12 to 20 gauge needle– Gauze– Tubing – 10 or 20 cc syringe or IV bag
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Technique: Intraosseous Needle Holder
QuickTime™ and a decompressor
are needed to see this picture.
Designed and made by Richard Near
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Technique
• Choice of needle:– Children
• < 18 months– 16, 18, or 20 gauge needle
• 18 months to 6 years– 12, 14, 16 gauge needle
– Older children and adults• 12 or 14 gauge needle
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Technique
• Usually use proximal tibia because easy to landmark
• Need to be distal to growth plate in children
• Landmark– Palpate tibial tuberosity– Move distal 2 cm and slightly medial– Relatively flat area
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Technique• Place small towel behind knee • Restrain leg
• Use local anesthetic in subcutaneous tissue and periosteum if patient conscious as the procedure is painful
• Put on gloves / Drape area / Sterile technique
• Load needle onto IO needle holder
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Technique• Landmark and insert needle angled to 10-15º caudally -- to
avoid injury to growth plate
• Insert through skin until you feel bone
• Begin to twist and push - Keep index finger down on IO holder to prevent plunging in
• You will feel a ‘pop’ when you reach marrow
• Immediately flush small amount of sterile fluid through needle to dislodge ‘bone plug’
knee foot
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Technique• Confirm proper location of needle before
starting infusion– Needle should stand on its own without support if it is
through bone cortex– Aspirate blood or marrow– 5-10 ml bolus should enter with little resistance and
with no extravasation
• If you make a hole in the cortex, do not put another hole in the cortex of the same bone as this will result in possible fluid extravasation into the soft tissue
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Technique
• Attach stopcock or syringe or IV tubing
• Tape gauze pads around needle to stabilize it
• Should use IO access for resuscitation and replace with conventional IV line when resuscitation is completed– IO lines should not be used for a prolonged period
of time to minimize risk of osteomyelitis
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Technique• Use syringe to give fluid bolus
– If needle is attached to IV tubing, you need pressure bag or pump to infuse at a rapid rate
• Use isotonic solution (normal saline)
• For resuscitation in children:
20 ml / kg
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Possible Complication
• Extravasation of fluid into subcutaneous tissue– Most common complication– Caused by:
• Misplaced needle• Multiple attempts (put other holes in bone)• Enlargement of IO hole from needle movement
– May result in:• Subcutaneous tissue or muscle necrosis• Compartment syndrome
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Possible Complications
• Osteomyelitis– Incidence in children is 0.6%– Risk increased if:
• Prolonged use of IO needle• Pre-existing bacteremia• Use of hypertonic saline
• Other rare complications– Fracture at IO site– Compartment syndrome– Cellulitis or local abscess
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Preparation of IO Holder
• Needs to be cleaned and sterilized after each use
• Can be used and cleaned like all other surgical instruments because it is stainless steel
• Method– Cleaning– Sterilization
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Preparation of IO Holder
• Cleaning – Use scrub brush – Decreases possible pieces of blood and
tissue that prevents heat or chemical sterilization
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Preparation of IO Holder
• Chemical Sterilization– Undiluted bleach or 1:1 bleach dilution
• Kills bacteria, virus, fungus, TB (not bacterial spores)• Needs 1 hour contact, then rinse with sterile water
– 2% glutaraldehyde• Needs 6-10 hour contact, then rinse with sterile water
• Heat Sterilization– Autoclave
• Unwrapped at 124ºC for 15 minutes• Kills bacteria, virus, fungus, TB, and bacterial spores
– Steam Sterilization• Wrapped at 121ºC for 30 minutes
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Review
• Important way to gain emergency IV access for resuscitation when other methods have failed
• Placement of needle is in flat area medial and distal to tibial tuberosity
• Confirm position and stabilize needle• Bolus 20 ml / kg in children• Replace with conventional IV line when
resuscitation completed
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References
• Intraosseous Infusion– Brian LaRocco, Henry Wang– Prehospital Emergency Care 2003;7:280-285
• Clinical Review: Vascular Access for fluid infusion in children– Nikolaus Haas– Critical Care 2004;8(6):478-484