NATIONAL HARBOR, MD. – When a child needs fluids or drugs but you can’t find a good vein, turn to bone.
Intraosseous (IO) access was pioneered during World War I, and it’s aged well – although peripheral IVs pushed it out of the limelight for several decades. But IO access remains the standard of care in emergency situations where IVs can’t be used, Dr. Angela Ellison said at a meeting sponsored by the American College of Emergency Physicians.
Dr. Angela Ellison
A 1988 review of 33 pediatric cardiac arrests showed that IO is the quickest way to go. Although a successful IO attempt took about 5 minutes, compared with 3 minutes for a peripheral IV, the success rate for an IO placement was much greater – 83% vs. 17%, said Dr. Ellison of the University of Pennsylvania, Philadelphia (Am. J. Emerg. Med. 1988;6:577-9).
"In difficult cases, the investigators recommended that IV attempts be very brief, and if unsuccessful, you should move on to IO right away," she said.
IO access works for children of all sizes, even newborns, she said, and in children with all kinds of emergencies, including shock, trauma, status epilepticus, and severe dehydration. IO access can be established by emergency medical technicians and nurses as well as physicians. With a preprocedural shot of lidocaine, IO catheters can easily be placed in conscious as well as unconscious patients.
For patients who need drugs urgently, IO is superior to IV; animal studies have shown that drugs reach the heart in 10-20 seconds, and there is no need to change the dose from a normal IV concentration.
Technical advances have made IO access easier, she added. "Over the past few decades, we’ve gotten a number of powered devices that have contributed to the rise of IO." Some can be placed in the sternum and others in long bones. Studies have shown that the complication rate is not increased when the needles are placed near a growth plate.
IO access is not for everyone or every bone, however. Contraindications include long bone fracture, vascular injury in the extremity, an overlying skin infection, a burn at the access site, 10 or more previous placements or attempts, and fragile bones (osteogenesis imperfecta or osteoporosis).
For the most part, however, IO access is very safe. Studies conducted in the late 1980s and early 1990s show an overall complication rate of less than 1%. Osteomyelitis occurred in 0.6%, and cellulitis or skin abscess developed in 0.7%. No evidence of bone deformity or growth arrest was seen in long-term follow-up studies.
Dr. Ellison had no financial conflicts.