Intraosseous needle insertion for neonates
- Intraosseous needle insertion is a procedure for obtaining access to the circulation in an emergency, including in some cases of cardiac arrest.
- This route can be used to administer recommended dosage of drugs & fluids & to collect blood for pathology. Always alert the laboratory if blood was collected from the IO, as the information may be relevant to the processing of the sample & interpretation of results.
- Follow procedural steps carefully to ensure successful insertion.
During the first week of life the umbilical vein is a convenient route for obtaining vascular access during emergencies.
The intraosseous (IO) route provides an option for establishing rapid venous access in an emergency after that time.
The bone marrow cavity has an extensive virtually non-collapsible vascular network which communicates directly with the systemic circulation.
Medications or fluids given by the IO route diffuse a few centimetres through the medullary cavity then enter the venous circulation.
Figure 1. The proximal tibia is the preferred site. The entry point is a few centimetres below the tibial tuberosity at the centre of the flat antero-medial surface. The needle is directed caudal away from the upper tibial epiphysis in the line of the shaft.
The distal antero-medial surface of the tibia is an alternate site which can be used in children of all ages.
The distal femur and sternum should not be used.
The following equipment is required to perform an intraosseous needle insertion:
- sterile gloves and gown
- basic dressing pack
- antiseptic to prepare the skin
- rigid needle with an inner stylet (for patients < 18 months an 18 - 20 lumbar puncture needle can be used)
- syringe with NaCl 0.9% flush
- routine IV line tubing set-up and tape
Follow this procedure during an intraosseous needle insertion:
- Observe standard precautions.
- Immobilize the extremity.
- Prepare the site with antiseptic.
- Consider need to use local anaesthetic( 0.5-1 mL 1% lignocaine ) if time permits.
- Insert the needle:Hold the needle handle in the palm of the hand while the thumb and forefinger grip the shaft about a centimetre from the point to stabilize the needle.
- Apply firm pressure while using a screwing or rotary action until the bone cortex is traversed.
- Note that at approximately 1cm or less below the skin surface, a distinct loss of resistance on entry of the bone marrow is felt.
- Blockage of the needle may occurr if an inner stylet is not used.
Three indicators of successful insertion
You should notice these three things if the intraosseous needle insertion has been successful:
- A distinctive pop with insertion, or a give or release of resistance is felt.
- The needle flushes without significant subcutaneous infiltration and bone marrow is easily aspirated.
- The needle stands without support.
After successful insertion
Once insertion is confirmed:
- Unscrew and remove the stylet.
- Attempt bone marrow aspiration (bone marrow can be used as a substitute for venous blood for estimation of PCO2, pH, Hb, electrolytes, urea, creatinine, proteins etc).
- Flush the needle with 5-10 mL of normal saline to decrease the cellularity of the surrounding marrow, aiding subsequent infusions.
- Attach IV tubing and commence the infusion of medications or fluids by pump.
Recommended intravenous rates for drugs and fluids can be administered via the IO route and reach the central circulation in equivalent times.
Strong alkaline and hypertonic solutions should be diluted before use.
- osteogenesis imperfecta
- limb is traumatised
Possible complications of intraosseous needle insertion include:
- Extravasation of fluid, drugs or air into the skin or periosteum through the hole in the bone. A larger hole is created if a rocking motion is used during insertion of the needle. It may also occur if there has been a previous IO infusion in the same bone.
- Sub-periosteal infusion may occur when the needle fails to enter the bone marrow.
- Through and through puncture occurs if the needle is advanced too far. This carries a risk for compartment syndrome if fluid is infused into a muscle compartment.
- Infection (cellulitis, abscess formation, skin necrosis and osteomyelitis).
- Tibial fracture
- Fat and bone marrow microemboli.