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Intraosseous Access for Administration of Medications in Neonates
Clin Perinatol 33 (2006) 161 – 168
Intraosseous Access for Administration of Medications in Neonates William A. Engle, MD Department of Pediatrics, James Whitcomb Riley Hospital, Indiana University School of Medicine, 699 West Drive, RR-208, Indianapolis, IN 46202-5119, USA
Intraosseous access is an alternative route to the intravascular space when intravenous access cannot be established quickly. The intraosseous route is used most often in infants and young children who require emergent vascular access during cardiopulmonary resuscitation. Intraosseous access and infusion also has been used successfully in a few sick neonates [1–5]. There are no previous guidelines regarding the use of intraosseous access in neonates. The International Liaison Committee on Resuscitation considered whether the intraosseous route was a suitable alternative method for infusing fluids and medications during newborn resuscitation in the ICU when intravenous access is unsuccessful [1–5].
Evidence review An electronic search of Medline (Ovid), Embase, and the Cochrane Database of Systematic Reviews was undertaken. Bibliographies of journal and review articles were hand-searched for additional references. Search criteria included neonatal human studies. The body of literature specifically focused on neonates yielded 56 articles pertaining to intraosseous access in neonates and young infants. Four case reports and a single series of 27 preterm and term neonates showed that intraosseous access could be used successfully in sick neonates within a neonatal ICU when intravenous access was unsuccessful [1–5]. This article reviews the history, physiology, technique, indications, and complications of intraosseous access and infusions. Information from use in children and adults forms the basis of this review because of limited information in neonates [1–5]. E-mail address: [email protected] 0095-5108/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.clp.2005.11.006 perinatology.theclinics.com
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History Infusions of blood and other fluids into the circulation by way of the bone marrow was first described in the 1940s as an alternative to infusion through the superior sagittal sinus in newborns and when intravenous access was impossible in older children and adults (eg, widespread mutilations, burns, edema, poorly developed or obliterated veins, states of shock) [6,7]. Tocantins et al [8] reported the technique, results, and success during traumatic shock and other forms of circulatory failure. These case series included 57 patients, of which 9 were less than 2 years old; one infant was 8 days old. Infusion into the 8-day-old infant was abandoned because of a very slow infusion rate, probably as a result of the catheter being partially obstructed with bony material or clot. The rate of infusion by gravity through the proximal tibia or distal femur in the infants in these original studies was 0.5 to 4.2 mL/min (average 1.7 mL/min). More rapid infusions were possible with the use of a syringe, although rapid injection was recommended only during states of shock. Several additional important observations about intraosseous access and infusions were made during these landmark studies [6,7]. The technique of intraosseous access was quick and could be established more rapidly than an intravenous catheter; this was important when rapid access to the intravascular space was needed. Infusions of blood, salt solutions, glucose, and medications were possible. The intraosseous placement of the needle was relatively easy to learn and required simple equipment; it was ideal for vascular access on the battlefield, scenes of accidents, or during transport. Intraosseous access also was found to cause discomfort during placement of the needle, but infusion of blood or salt solutions was generally painless. The most accessible marrow sites were the sternum in adults and tibia or femur in infants and young children, sites of very vascular bone marrow with relatively little fat. Placing the needle at an angle away from the epiphysis of the long bones was important to avoid injury and abnormal bone growth. Infusions could be continued for long periods (eg, 30.5 hours in one patient), and repeat access to the same site was possible after a 1- or 2-day respite. Complications included obstruction secondary to bony spicules; the needle tip abutting against the bony wall; and clots, especially if the infusion buret was positioned below the access site and bone marrow was allowed to backfill into the needle. Other complications included infection, infiltration of tissues when the needle was displaced, air or fat emboli, and technique failure secondary to needle placement in bone that had limited marrow or was very thick (eg, clavicle or bone marrow infiltrated with cells, fibrous tissue, or excess bone). Heinild et al in 1946 [9] reported the experience with 1000 bone marrow infusions in 495 children less than 4 years old. Preterm infants weighing 1150 g, 1200 g, and 1750 g at birth were treated successfully using an intraosseous infusion in this series. Success rates with intraosseous infusions was 98.2%, although in approximately 8% the infusion was interrupted to change the intraosseous site, resolve a hematoma, or replace a bent needle. Hypertonic solutions
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(50% glucose or concentrated serum) were associated with a high rate of osteomyelitis (13%), although osteomyelitis occurred in only approximately 1% of all patients. Scarring at the access sites was present in some cases years after infusions. Radiographs did not show long-term abnormalities of the bone, however. Intraosseous vascular access for short-term administration of fluids or medications was nearly abandoned during the 1950s through 1980s with the introduction of plastic catheters that allowed more prolonged vascular access [10]. Renewed interest in techniques that were simple and reliable and allowed quick access to the vascular space accompanied the growing interest in cardiopulmonary resuscitation of pediatric patients in the 1980s [11–13]. Subsequently, case reports and a case series of term and preterm neonates resuscitated with intraosseous access devices pointed out the potential for application during neonatal cardiopulmonary stabilization [1,3–5].
Technique The technique to establish an intraosseous route for vascular access in young children has been reviewed by several authors [11–18]. The proximal tibia is the most commonly used site for intraosseous access in infants and children. The distal femur, medial or lateral malleoli, and iliac crests are alternative locations. The proximal tibial site is approximately 1 cm below the tibial tuberosity and medially located on the tibial plateau. The distal femur location is approximately 1 cm above the patella in the midline, and malleoli sites are approximately 1 cm superior to the malleoli in the midline. The medial malleolus is generally easier to penetrate than the lateral malleolus. Several intraosseous needles are commercially available. Generally, they contain a stylet to prevent plugging with bone spicules and are rigid [12,14,18]. If an intraosseous needle is unavailable, a large-gauge needle with a stylet, such as a lumbar puncture needle or hypodermic needle, may suffice. A largebore butterfly needle may be used, but plugging may complicate the success of the procedure. Local anesthesia is appropriate in a conscious patient before placement of an intraosseous needle. The needle should be introduced nearly perpendicular to the bone using a back-and-forth twisting motion [12,17]. Some experts suggest introducing the needle at a 608 to 758 angle, but this angle of insertion risks the needle sliding and scraping along the bone [18]. The needle always should be advanced in a direction away from the epiphyseal plates or joint cavity. Entrance into the marrow space is sensed when a ‘‘give’’ or decrease in resistance occurs, and the needle stands on its own. To confirm placement within the marrow, a syringe should be attached, and blood or marrow should be aspirated. Moderate force must be applied to aspirate bone marrow. Marrow is a gelatinous red fluid containing fat globules and bony spicules. If cardiac arrest is occurring or small needles (18G to 20G) are used, bone marrow may not be aspirated [12]. In these instances, slow infusion of a saline solution with close palpation for
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engle
extravasation is recommended to ensure proper position. The insertion procedure generally takes only a few minutes [1,12,19]. The needle should stand on its own if properly positioned, but should be protected with a supportive dressing. Antibiotic coverage for staphylococci also is recommended by some experts after emergent placements using less than ideal sterile conditions [18]. If unsuccessful at one site, another site should be selected for subsequent placement attempts [12].
Physiology The long bones are composed of a dense outer layer of bone that surrounds a spongy medullary cavity (Fig. 1). The medullary cavity contains bone marrow, fat tissue, blood vessels, and nerves. After 5 years of age, the red marrow is replaced by the less vascular yellow marrow in the long bones of children, making access more difficult. The thin mantle of bone in the sternum of young infants and children and ease of needle insertion penetrating through the back of the sternum argue against the sternum as a site for bone marrow access in children younger than 3 to 5 years old [13]. Blood cell production and blood supply to the bone itself are the primary functions of the medullary cavity.
Fig. 1. Anatomy of the proximal tibia and vascular structures with intraosseous needle in situ.
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Medullary venous sinusoids drain into the central venous channel and exit the bone through nutrient or emissary veins that connect to the central circulation. The outer layer of bone supports the medullary cavity, allowing it to serve as a ‘‘noncollapsible vein.’’
Clinical indications Intravascular access may be required during resuscitation of some neonates and young children. The key to resuscitation in neonates is adequate ventilation. Respiratory insufficiency accounts for most cardiopulmonary arrests in this age group [19,20]. Administration of chest compressions and medications during cardiopulmonary resuscitations of neonates in the delivery room occurred in only 0.12% of 30,839 newborns delivered during a 2-year period [20]. Nevertheless, clinicians caring for newborns and young infants who require resuscitation should be poised to secure intravascular access. In the delivery room, the umbilical vein is a readily accessible site for venous cannulation [19]. Neonatal resuscitation education programs often include special training for umbilical vein cannulation [19]. Intraosseous access is an alternative in the rare instance when neither umbilical nor peripheral venous access is successful [1,19]. Medical students who had not been trained in umbilical vein cannulation or intraosseous access were asked to perform these procedures using plastic models and turkey tibiae [21]. Intraosseous access was found to be easier and faster than umbilical venous catheter placement. Neonates requiring resuscitation outside of the delivery room, whether at home, at an accident scene, or in the hospital without vascular access (eg, complex congenital heart patient with sudden cardiac arrest), may be candidates for intraosseous access [1,22]. The need for such access is rare [23]. Only 0.5% of 555 pediatric patients transported for possible advanced life support had intraosseous needles placed [23]. Attaining vascular access in pediatric patients is an important adjunct to care during these rare circumstances [22,23]. Intraosseous access has been achieved more rapidly and successfully in newborns and young infants in nonhospital locations compared with intravenous access [18,24]. Placement and use of intraosseous access devices are important skills for medical caregivers providing care to unstable infants and children outside the delivery room. The limited clinical opportunity to do an infrequently performed procedure such as placement of an intraosseous needle requires additional technical retraining on a regular basis [22,23]. Infusion of fluids and medications into the venous circulation can be accomplished within 10 to 20 seconds using bone marrow needles inserted into the tibia or femur [11,12]. The rates of infusion by gravity through the bone marrow are generally slower than through an intravenous route; the rate can be increased using infusion pumps. If rapid volume replacement is indicated, more than one intraosseous site may be required. Infiltration may occur more quickly with high infusion rates or infusion of hypertonic solutions.
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The emergency administration of many medications through an intraosseous route has been followed by anticipated clinical responses in a time similar to intravenous administration [11–13,18]. A depot effect may occur with intraosseous medications, which is reflected in lower peak serum levels and a longer period of elevated drug levels compared with medications given intravenously [12]. A small saline bolus after administration of a resuscitation medication may increase the marrow flow and drug delivery from the bone marrow. Although data are limited for many medications, successful infusion of blood, saline, Ringer’s lactate, glucose solutions, and plasma has been reported many times. Additionally, emergency administration of resuscitation medications, including sodium bicarbonate, atropine, epinephrine, dopamine, lidocaine, diazepam, insulin, calcium gluconate, antibiotics, phenytoin, succinylcholine, and adenosine, has been reported [12,13]. Onset of epinephrine effect may be 17 seconds with peak effect within 45 seconds [11]. It generally is recommended that drug and fluid dosing is similar to the dosing used during intravenous infusions [11–13]. Laboratory studies can be assessed from bone marrow samples and are interpreted as ‘‘mixed venous’’ samples. Chemistries, hemoglobin, blood gases (especially pH and Pco2), blood cultures, and blood typing are reliable compared with venous samples. Correlations are best immediately after placement of the intraosseous needle. Accuracy of bone marrow sample results is reduced with longer durations of infusions and sodium bicarbonate administration [14].
Complications Intraosseous medication and fluid administration is invasive, and complications may occur. The risk of complications is low, however. Osteomyelitis occurs in less than 1% of patients and has been associated with hypertonic fluid or medication infusion [9,11,12,18]. Subperiosteal or soft tissue extravasation, compartment syndrome, air or fat embolism, abnormal bone growth, medication or transfusion reactions, local tissue reactions, mediastinitis, and abscess formation also may complicate intraosseous infusions [11,25]. Fractures are distinctly rare.
Contraindications Bone disease is a contraindication for placement of an intraosseous needle or infusion [11,12,18]. This is particularly true for infants with osteogenesis imperfecta, osteopetrosis, or other illnesses associated with a propensity to fracture. A previously used site of an intraosseous needle is a relative contraindication for a short time (1–2 days) because fluid may leak through unhealed needle tracts. Overlying cellulitis, burn, and other infection are additional contraindications.
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Gaps in knowledge Evidence to support use of the intraosseous route for vascular access in neonates is limited to case reports and biologic plausibility. Randomized or historical controlled trials in neonates are unlikely because venous access is nearly always obtainable, and the incidence of resuscitations requiring intravascular access is low. Because clinical reports are limited to descriptions of successful cases, no information is available on success rates, complication rates, or best needle types in the neonatal population. The pharmacology of drug administration through intraosseous sites in neonates is unexplored.
Summary Intraosseous administration of resuscitation medications and fluids in preterm and term neonates is an alternative when intravascular access is not possible with intravenous catheters or needles. Intraosseous access is rarely needed in neonates because of the availability of clinicians with expert technical skills for placement of intravenous catheters in neonatal ICUs, the presence of the umbilical vein during the first days after birth when most resuscitations occur, and the predominance of resuscitations being responsive to positive-pressure ventilation alone. Intraosseous access is most likely to be needed in out-of-hospital settings and in hospitalized infants without intravenous access who have vascular collapse secondary to shock or when clinicians responsible for vascular access during resuscitations are more skilled in intraosseous access than intravenous access.
References [1] Ellemunter H, Simma B, Trawoger R, et al. Intraosseous lines in preterm and full term neonates. Arch Dis Child Fetal Neonatal Ed 1999;80:F74 – 5. [2] Alba M, Lopez R. Use of the intraosseous route in resuscitation in a neonate. Intensive Care Med 1994;20:529. [3] Nasimi A, Gorin P, Berthier M, et al. Utilisation de la voie intraosseuse chez un premature. Arch Pediatr 1998;5:414 – 7. [4] Kelsall AWR. Resuscitation with intraosseous lines in neonatal units. Arch Dis Child 1993;68: 324 – 5. [5] Ramet J, Clybouw C, Benatar A, et al. Successful use of an intraosseous infusion in an 800 grams preterm infant. Eur J Emerg Med 1998;5:327 – 8. [6] Tocantins LM, O’Neill JF. Infusion of blood and other fluids into the circulation via the bone marrow. Proc Soc Exp Biol Med 1940;45:782 – 3. [7] Tocantins LM, O’Neill JF. Infusions of blood and other fluids into the general circulation via the bone marrow. Surg Gynecol Obstet 1941;73:281 – 7. [8] Tocantins LM, O’Neill JF, Price AH. Infusions of blood and other fluids via the bone marrow in traumatic shock and other forms of peripheral circulatory failure. Ann Surg 1941;114:1085 – 92. [9] Heinild S, Tyge S, Tudvad F. Bone marrow infusion in childhood. J Pediatr 1947;30:400 – 12. [10] Bohn D. Intraosseous vascular access: from the archives to the ABC. Crit Care Med 1999;27: 1053 – 4.
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[11] Rosetti VA, Thompson BM, Miller J, et al. Intraosseous infusion: an alternative route of pediatric intravascular access. Ann Emerg Med 1985;14:885 – 8. [12] Spivey WH. Intraosseous infusions. J Pediatr 1987;111:639 – 43. [13] Jaimovich DG, Kecskes S. Intraosseous infusion: a re-discovered procedure as an alternative for pediatric vascular access. Indian J Pediatr 1991;58:329 – 34. [14] Zaritsky AL, Nadkarni UM, Hickey RW, et al. PALS provider manual. Dallas (TX)7 American Heart Association/American Academy of Pediatrics; 2002. [15] Evans RJ, McCabe M, Thomas R. Intraosseous infustion. Br J Hosp Med 1994;51:161 – 4. [16] Neal CJ, McKinley DF. Intraosseous infusion in pediatric patients. J Am Osteopath Assoc 1994;94:63 – 6. [17] LaRocco BG, Wang HE. Intraosseous infusion. Prehosp Emerg Care 2003;7:280 – 5. [18] Orlowski JP. Emergency alternatives to intravenous access. Pediatr Crit Care 1994;41:1183 – 99. [19] International Guidelines for Neonatal Resuscitation. An excerpt from the guideline 2000 for cardiopulmonary resuscitation and emergency cardiovascular care: international consensus on science. Pediatrics 2000;106:1 – 16. [20] Perlman JM, Risser R. Cardiopulmonary resuscitation in the delivery room. Arch Pediatr Adolesc Med 1995;149:20 – 5. [21] 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;18:126 – 9. [22] Fiorito BA, Farrukh M, Doran TM, et al. Intraosseous access in the setting of pediatric critical transport. Pediatr Crit Care Med 2005;6:50 – 3. [23] Babl FE, Vinci RJ, Bauchner H, et al. Pediatric pre-hospital advanced life support care in an urban setting. Pediatr Emerg Care Feb 2001;17:5 – 9. [24] Glaeser PW, Hellmich TR, Szewczuga D, et al. Five-year experience in prehospital intraosseous infusions in children and adults. Ann Emerg Med 1993;22:1119 – 24. [25] Claudet I, Baunin C, Laporte-Turpin E, et al. Long-term effects on tibial growth after intraosseous infusion: a prospective, radiographic analysis. Pedatr Emerg Care 2003;19:397 – 401.
Intraosseous Access for Administration of Medications in Neonates William A. Engle, MD Department of Pediatrics, James Whitcomb Riley Hospital, Indiana University School of Medicine, 699 West Drive, RR-208, Indianapolis, IN 46202-5119, USA
Intraosseous access is an alternative route to the intravascular space when intravenous access cannot be established quickly. The intraosseous route is used most often in infants and young children who require emergent vascular access during cardiopulmonary resuscitation. Intraosseous access and infusion also has been used successfully in a few sick neonates [1–5]. There are no previous guidelines regarding the use of intraosseous access in neonates. The International Liaison Committee on Resuscitation considered whether the intraosseous route was a suitable alternative method for infusing fluids and medications during newborn resuscitation in the ICU when intravenous access is unsuccessful [1–5].
Evidence review An electronic search of Medline (Ovid), Embase, and the Cochrane Database of Systematic Reviews was undertaken. Bibliographies of journal and review articles were hand-searched for additional references. Search criteria included neonatal human studies. The body of literature specifically focused on neonates yielded 56 articles pertaining to intraosseous access in neonates and young infants. Four case reports and a single series of 27 preterm and term neonates showed that intraosseous access could be used successfully in sick neonates within a neonatal ICU when intravenous access was unsuccessful [1–5]. This article reviews the history, physiology, technique, indications, and complications of intraosseous access and infusions. Information from use in children and adults forms the basis of this review because of limited information in neonates [1–5]. E-mail address: [email protected] 0095-5108/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.clp.2005.11.006 perinatology.theclinics.com
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engle
History Infusions of blood and other fluids into the circulation by way of the bone marrow was first described in the 1940s as an alternative to infusion through the superior sagittal sinus in newborns and when intravenous access was impossible in older children and adults (eg, widespread mutilations, burns, edema, poorly developed or obliterated veins, states of shock) [6,7]. Tocantins et al [8] reported the technique, results, and success during traumatic shock and other forms of circulatory failure. These case series included 57 patients, of which 9 were less than 2 years old; one infant was 8 days old. Infusion into the 8-day-old infant was abandoned because of a very slow infusion rate, probably as a result of the catheter being partially obstructed with bony material or clot. The rate of infusion by gravity through the proximal tibia or distal femur in the infants in these original studies was 0.5 to 4.2 mL/min (average 1.7 mL/min). More rapid infusions were possible with the use of a syringe, although rapid injection was recommended only during states of shock. Several additional important observations about intraosseous access and infusions were made during these landmark studies [6,7]. The technique of intraosseous access was quick and could be established more rapidly than an intravenous catheter; this was important when rapid access to the intravascular space was needed. Infusions of blood, salt solutions, glucose, and medications were possible. The intraosseous placement of the needle was relatively easy to learn and required simple equipment; it was ideal for vascular access on the battlefield, scenes of accidents, or during transport. Intraosseous access also was found to cause discomfort during placement of the needle, but infusion of blood or salt solutions was generally painless. The most accessible marrow sites were the sternum in adults and tibia or femur in infants and young children, sites of very vascular bone marrow with relatively little fat. Placing the needle at an angle away from the epiphysis of the long bones was important to avoid injury and abnormal bone growth. Infusions could be continued for long periods (eg, 30.5 hours in one patient), and repeat access to the same site was possible after a 1- or 2-day respite. Complications included obstruction secondary to bony spicules; the needle tip abutting against the bony wall; and clots, especially if the infusion buret was positioned below the access site and bone marrow was allowed to backfill into the needle. Other complications included infection, infiltration of tissues when the needle was displaced, air or fat emboli, and technique failure secondary to needle placement in bone that had limited marrow or was very thick (eg, clavicle or bone marrow infiltrated with cells, fibrous tissue, or excess bone). Heinild et al in 1946 [9] reported the experience with 1000 bone marrow infusions in 495 children less than 4 years old. Preterm infants weighing 1150 g, 1200 g, and 1750 g at birth were treated successfully using an intraosseous infusion in this series. Success rates with intraosseous infusions was 98.2%, although in approximately 8% the infusion was interrupted to change the intraosseous site, resolve a hematoma, or replace a bent needle. Hypertonic solutions
intraosseous access
163
(50% glucose or concentrated serum) were associated with a high rate of osteomyelitis (13%), although osteomyelitis occurred in only approximately 1% of all patients. Scarring at the access sites was present in some cases years after infusions. Radiographs did not show long-term abnormalities of the bone, however. Intraosseous vascular access for short-term administration of fluids or medications was nearly abandoned during the 1950s through 1980s with the introduction of plastic catheters that allowed more prolonged vascular access [10]. Renewed interest in techniques that were simple and reliable and allowed quick access to the vascular space accompanied the growing interest in cardiopulmonary resuscitation of pediatric patients in the 1980s [11–13]. Subsequently, case reports and a case series of term and preterm neonates resuscitated with intraosseous access devices pointed out the potential for application during neonatal cardiopulmonary stabilization [1,3–5].
Technique The technique to establish an intraosseous route for vascular access in young children has been reviewed by several authors [11–18]. The proximal tibia is the most commonly used site for intraosseous access in infants and children. The distal femur, medial or lateral malleoli, and iliac crests are alternative locations. The proximal tibial site is approximately 1 cm below the tibial tuberosity and medially located on the tibial plateau. The distal femur location is approximately 1 cm above the patella in the midline, and malleoli sites are approximately 1 cm superior to the malleoli in the midline. The medial malleolus is generally easier to penetrate than the lateral malleolus. Several intraosseous needles are commercially available. Generally, they contain a stylet to prevent plugging with bone spicules and are rigid [12,14,18]. If an intraosseous needle is unavailable, a large-gauge needle with a stylet, such as a lumbar puncture needle or hypodermic needle, may suffice. A largebore butterfly needle may be used, but plugging may complicate the success of the procedure. Local anesthesia is appropriate in a conscious patient before placement of an intraosseous needle. The needle should be introduced nearly perpendicular to the bone using a back-and-forth twisting motion [12,17]. Some experts suggest introducing the needle at a 608 to 758 angle, but this angle of insertion risks the needle sliding and scraping along the bone [18]. The needle always should be advanced in a direction away from the epiphyseal plates or joint cavity. Entrance into the marrow space is sensed when a ‘‘give’’ or decrease in resistance occurs, and the needle stands on its own. To confirm placement within the marrow, a syringe should be attached, and blood or marrow should be aspirated. Moderate force must be applied to aspirate bone marrow. Marrow is a gelatinous red fluid containing fat globules and bony spicules. If cardiac arrest is occurring or small needles (18G to 20G) are used, bone marrow may not be aspirated [12]. In these instances, slow infusion of a saline solution with close palpation for
164
engle
extravasation is recommended to ensure proper position. The insertion procedure generally takes only a few minutes [1,12,19]. The needle should stand on its own if properly positioned, but should be protected with a supportive dressing. Antibiotic coverage for staphylococci also is recommended by some experts after emergent placements using less than ideal sterile conditions [18]. If unsuccessful at one site, another site should be selected for subsequent placement attempts [12].
Physiology The long bones are composed of a dense outer layer of bone that surrounds a spongy medullary cavity (Fig. 1). The medullary cavity contains bone marrow, fat tissue, blood vessels, and nerves. After 5 years of age, the red marrow is replaced by the less vascular yellow marrow in the long bones of children, making access more difficult. The thin mantle of bone in the sternum of young infants and children and ease of needle insertion penetrating through the back of the sternum argue against the sternum as a site for bone marrow access in children younger than 3 to 5 years old [13]. Blood cell production and blood supply to the bone itself are the primary functions of the medullary cavity.
Fig. 1. Anatomy of the proximal tibia and vascular structures with intraosseous needle in situ.
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Medullary venous sinusoids drain into the central venous channel and exit the bone through nutrient or emissary veins that connect to the central circulation. The outer layer of bone supports the medullary cavity, allowing it to serve as a ‘‘noncollapsible vein.’’
Clinical indications Intravascular access may be required during resuscitation of some neonates and young children. The key to resuscitation in neonates is adequate ventilation. Respiratory insufficiency accounts for most cardiopulmonary arrests in this age group [19,20]. Administration of chest compressions and medications during cardiopulmonary resuscitations of neonates in the delivery room occurred in only 0.12% of 30,839 newborns delivered during a 2-year period [20]. Nevertheless, clinicians caring for newborns and young infants who require resuscitation should be poised to secure intravascular access. In the delivery room, the umbilical vein is a readily accessible site for venous cannulation [19]. Neonatal resuscitation education programs often include special training for umbilical vein cannulation [19]. Intraosseous access is an alternative in the rare instance when neither umbilical nor peripheral venous access is successful [1,19]. Medical students who had not been trained in umbilical vein cannulation or intraosseous access were asked to perform these procedures using plastic models and turkey tibiae [21]. Intraosseous access was found to be easier and faster than umbilical venous catheter placement. Neonates requiring resuscitation outside of the delivery room, whether at home, at an accident scene, or in the hospital without vascular access (eg, complex congenital heart patient with sudden cardiac arrest), may be candidates for intraosseous access [1,22]. The need for such access is rare [23]. Only 0.5% of 555 pediatric patients transported for possible advanced life support had intraosseous needles placed [23]. Attaining vascular access in pediatric patients is an important adjunct to care during these rare circumstances [22,23]. Intraosseous access has been achieved more rapidly and successfully in newborns and young infants in nonhospital locations compared with intravenous access [18,24]. Placement and use of intraosseous access devices are important skills for medical caregivers providing care to unstable infants and children outside the delivery room. The limited clinical opportunity to do an infrequently performed procedure such as placement of an intraosseous needle requires additional technical retraining on a regular basis [22,23]. Infusion of fluids and medications into the venous circulation can be accomplished within 10 to 20 seconds using bone marrow needles inserted into the tibia or femur [11,12]. The rates of infusion by gravity through the bone marrow are generally slower than through an intravenous route; the rate can be increased using infusion pumps. If rapid volume replacement is indicated, more than one intraosseous site may be required. Infiltration may occur more quickly with high infusion rates or infusion of hypertonic solutions.
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engle
The emergency administration of many medications through an intraosseous route has been followed by anticipated clinical responses in a time similar to intravenous administration [11–13,18]. A depot effect may occur with intraosseous medications, which is reflected in lower peak serum levels and a longer period of elevated drug levels compared with medications given intravenously [12]. A small saline bolus after administration of a resuscitation medication may increase the marrow flow and drug delivery from the bone marrow. Although data are limited for many medications, successful infusion of blood, saline, Ringer’s lactate, glucose solutions, and plasma has been reported many times. Additionally, emergency administration of resuscitation medications, including sodium bicarbonate, atropine, epinephrine, dopamine, lidocaine, diazepam, insulin, calcium gluconate, antibiotics, phenytoin, succinylcholine, and adenosine, has been reported [12,13]. Onset of epinephrine effect may be 17 seconds with peak effect within 45 seconds [11]. It generally is recommended that drug and fluid dosing is similar to the dosing used during intravenous infusions [11–13]. Laboratory studies can be assessed from bone marrow samples and are interpreted as ‘‘mixed venous’’ samples. Chemistries, hemoglobin, blood gases (especially pH and Pco2), blood cultures, and blood typing are reliable compared with venous samples. Correlations are best immediately after placement of the intraosseous needle. Accuracy of bone marrow sample results is reduced with longer durations of infusions and sodium bicarbonate administration [14].
Complications Intraosseous medication and fluid administration is invasive, and complications may occur. The risk of complications is low, however. Osteomyelitis occurs in less than 1% of patients and has been associated with hypertonic fluid or medication infusion [9,11,12,18]. Subperiosteal or soft tissue extravasation, compartment syndrome, air or fat embolism, abnormal bone growth, medication or transfusion reactions, local tissue reactions, mediastinitis, and abscess formation also may complicate intraosseous infusions [11,25]. Fractures are distinctly rare.
Contraindications Bone disease is a contraindication for placement of an intraosseous needle or infusion [11,12,18]. This is particularly true for infants with osteogenesis imperfecta, osteopetrosis, or other illnesses associated with a propensity to fracture. A previously used site of an intraosseous needle is a relative contraindication for a short time (1–2 days) because fluid may leak through unhealed needle tracts. Overlying cellulitis, burn, and other infection are additional contraindications.
intraosseous access
167
Gaps in knowledge Evidence to support use of the intraosseous route for vascular access in neonates is limited to case reports and biologic plausibility. Randomized or historical controlled trials in neonates are unlikely because venous access is nearly always obtainable, and the incidence of resuscitations requiring intravascular access is low. Because clinical reports are limited to descriptions of successful cases, no information is available on success rates, complication rates, or best needle types in the neonatal population. The pharmacology of drug administration through intraosseous sites in neonates is unexplored.
Summary Intraosseous administration of resuscitation medications and fluids in preterm and term neonates is an alternative when intravascular access is not possible with intravenous catheters or needles. Intraosseous access is rarely needed in neonates because of the availability of clinicians with expert technical skills for placement of intravenous catheters in neonatal ICUs, the presence of the umbilical vein during the first days after birth when most resuscitations occur, and the predominance of resuscitations being responsive to positive-pressure ventilation alone. Intraosseous access is most likely to be needed in out-of-hospital settings and in hospitalized infants without intravenous access who have vascular collapse secondary to shock or when clinicians responsible for vascular access during resuscitations are more skilled in intraosseous access than intravenous access.
References [1] Ellemunter H, Simma B, Trawoger R, et al. Intraosseous lines in preterm and full term neonates. Arch Dis Child Fetal Neonatal Ed 1999;80:F74 – 5. [2] Alba M, Lopez R. Use of the intraosseous route in resuscitation in a neonate. Intensive Care Med 1994;20:529. [3] Nasimi A, Gorin P, Berthier M, et al. Utilisation de la voie intraosseuse chez un premature. Arch Pediatr 1998;5:414 – 7. [4] Kelsall AWR. Resuscitation with intraosseous lines in neonatal units. Arch Dis Child 1993;68: 324 – 5. [5] Ramet J, Clybouw C, Benatar A, et al. Successful use of an intraosseous infusion in an 800 grams preterm infant. Eur J Emerg Med 1998;5:327 – 8. [6] Tocantins LM, O’Neill JF. Infusion of blood and other fluids into the circulation via the bone marrow. Proc Soc Exp Biol Med 1940;45:782 – 3. [7] Tocantins LM, O’Neill JF. Infusions of blood and other fluids into the general circulation via the bone marrow. Surg Gynecol Obstet 1941;73:281 – 7. [8] Tocantins LM, O’Neill JF, Price AH. Infusions of blood and other fluids via the bone marrow in traumatic shock and other forms of peripheral circulatory failure. Ann Surg 1941;114:1085 – 92. [9] Heinild S, Tyge S, Tudvad F. Bone marrow infusion in childhood. J Pediatr 1947;30:400 – 12. [10] Bohn D. Intraosseous vascular access: from the archives to the ABC. Crit Care Med 1999;27: 1053 – 4.
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[11] Rosetti VA, Thompson BM, Miller J, et al. Intraosseous infusion: an alternative route of pediatric intravascular access. Ann Emerg Med 1985;14:885 – 8. [12] Spivey WH. Intraosseous infusions. J Pediatr 1987;111:639 – 43. [13] Jaimovich DG, Kecskes S. Intraosseous infusion: a re-discovered procedure as an alternative for pediatric vascular access. Indian J Pediatr 1991;58:329 – 34. [14] Zaritsky AL, Nadkarni UM, Hickey RW, et al. PALS provider manual. Dallas (TX)7 American Heart Association/American Academy of Pediatrics; 2002. [15] Evans RJ, McCabe M, Thomas R. Intraosseous infustion. Br J Hosp Med 1994;51:161 – 4. [16] Neal CJ, McKinley DF. Intraosseous infusion in pediatric patients. J Am Osteopath Assoc 1994;94:63 – 6. [17] LaRocco BG, Wang HE. Intraosseous infusion. Prehosp Emerg Care 2003;7:280 – 5. [18] Orlowski JP. Emergency alternatives to intravenous access. Pediatr Crit Care 1994;41:1183 – 99. [19] International Guidelines for Neonatal Resuscitation. An excerpt from the guideline 2000 for cardiopulmonary resuscitation and emergency cardiovascular care: international consensus on science. Pediatrics 2000;106:1 – 16. [20] Perlman JM, Risser R. Cardiopulmonary resuscitation in the delivery room. Arch Pediatr Adolesc Med 1995;149:20 – 5. [21] 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;18:126 – 9. [22] Fiorito BA, Farrukh M, Doran TM, et al. Intraosseous access in the setting of pediatric critical transport. Pediatr Crit Care Med 2005;6:50 – 3. [23] Babl FE, Vinci RJ, Bauchner H, et al. Pediatric pre-hospital advanced life support care in an urban setting. Pediatr Emerg Care Feb 2001;17:5 – 9. [24] Glaeser PW, Hellmich TR, Szewczuga D, et al. Five-year experience in prehospital intraosseous infusions in children and adults. Ann Emerg Med 1993;22:1119 – 24. [25] Claudet I, Baunin C, Laporte-Turpin E, et al. Long-term effects on tibial growth after intraosseous infusion: a prospective, radiographic analysis. Pedatr Emerg Care 2003;19:397 – 401.