Overview of Intraosseous Vascular Access

Intraosseous (IO) vascular access is a medical procedure where a special needle is inserted through the bone and into the marrow. This method is used for giving medications and performing blood tests, especially when it’s difficult or would take too long to insert a needle into a vein. This can often be the case in emergency or pre-hospital situations.

Studies have shown that IO vascular access is twice as successful as trying to place a needle in a vein in critical trauma patients who have low blood pressure. Therefore, it’s usually the first choice over intravenous (IV) placement in such situations.

Even though this method has a high success rate and is used by doctors, nurses, and paramedics on adults, children, and even animals, it’s not utilized as often as it could be. This can be down to factors such as doctors not feeling confident in when to use this method and nurses not being completely familiar with it.

Anything that is able to be given through an IV can be given through IO vascular access. However, this method should not be used for more than 24 hours due to an increased risk of complications. There are several different IO devices available, with some being easier to use and more appropriate for certain patients, including very young babies. What type is used can depend on what’s available at the hospital.

Anatomy and Physiology of Intraosseous Vascular Access

The sternum (breastbone), clavicle (collarbone), head of the humerus (the ball-like top of the long bone in your upper arm), iliac crest (the top edge of your hip), distal femur (the lower end of your thigh bone), proximal tibia (the upper end of your shin bone), distal tibia (the lower end of your shin bone), and calcaneus (heel bone) are all places in the body where doctors can gain what’s known as ‘intraosseous’ access. This means access into the inside of a bone, usually in an emergency when they need to give treatment or medication quickly.

For adult patients, the preferred spots are your upper arm bone, shin bone, or breastbone. For babies and very young children, the best spots are the ends of the thigh bone and shin bone.

When doctors are trying to get intraosseous access, they carefully feel the edges of the bone to make sure they’re inserting the needle right into the middle. They always measure a specific distance from a known point on the bone, usually about the width of one or two fingers, to find the right spot to insert the needle.

Description of the different sites:

– Sternum: The needle is inserted 1 cm below the notch at the top of your breastbone.

– Humerus: Your arm is positioned with the palm on your belly, and the elbow bent at a right angle. The doctor then finds the groove in the arm bone, and puts the needle around 2 cm above it and at an angle of about 45 degrees. This requires a longer needle to reach the inside of the bone.

– Distal Femur: With your leg straight, the needle goes into the bone 1 cm above your kneecap and slightly to the inside of your leg.

– Proximal and Distal Tibia: The needle goes into the shin bone about 1 cm to 2 cm below and to the inside of the bump on the inside of your leg and, for the lower end of the shin bone, about 2 cm above the bony lump on the inside of your ankle.

Why do People Need Intraosseous Vascular Access

If a doctor can’t find a vein to take blood or if it’s taking too long to find one, they may need to use a different type of procedure. Sometimes, it’s really urgent to get access to a vein, such as in emergency situations. Other times, a doctor might need to take a blood sample to help figure out a medical issue you’re experiencing or to perform tests on the spot. Also, if a special imaging test is planned that requires injecting a special dye (known as a contrast) into your bloodstream, a quicker way to access your vein may be required.

When a Person Should Avoid Intraosseous Vascular Access

There are a few reasons why a doctor might not be able to access a patient’s veins properly, which is needed for certain treatments or procedures. These could include:

1. If the patient has a broken bone where the doctor needs to access their veins – this area is called the boney site.
2. If the patient has a burn in the area where the doctor needs to access the vein.
3. If the patient has cellulitis (an infection of the skin) or another infection at the access site.
4. If the patient has a condition called Osteogenesis Imperfecta, which makes bones extremely fragile and likely to break.
5. If the patient has Osteoporosis, a condition that weakens bones and makes them fragile, this can also make vein access challenging.
6. If the doctor has previously tried to access the vein and was unsuccessful, or if there was another attempt to access the vein in the same place less than 48 hours earlier.
7. If the patient recently had orthopedic surgery, a surgery involving bones, it could also complicate vein access.

Equipment used for Intraosseous Vascular Access

There are a variety of tools that doctors use to perform an intraosseous (IO) insertion, which is a process of injecting directly into the marrow of a bone. These tools include the First Access for Shock and Trauma (FAST1), the EZ-IO, and the Bone Injection Gun (BIG). Other manual devices they might use are the Jamshidi needle and the Diekman modified needle.

Doctors need to follow the manufacturer’s instructions precisely while using these devices. All of these tools are used in a similar way, but when it comes to inserting a needle into the sternum (the flat bone in the middle of the chest), doctors need to use the FAST1 tool. This is because it prevents the needle from accidentally piercing too far into the body where it might harm the thoracic aorta, a major blood vessel in the chest.

Preparing for Intraosseous Vascular Access

Doctors will use a very clean method to perform the surgery. They’ll first identify the right location for the operation. If the patient is awake, they can choose to have a local anesthetic. This is a type of medicine that numbs a small area of the body and helps to reduce pain during the procedure. Although it’s not always necessary, it makes the procedure more comfortable for the patient. It’s worth noting that even without it, most patients tolerate the procedure quite well.

How is Intraosseous Vascular Access performed

Doctors use a process to insert a needle into a patient’s bone (commonly in the tibia – the shin bone), particularly when normal ways of giving medicine or fluids aren’t possible. This can sometimes be a need in babies or children, and special care is given to avoid hitting a sensitive area of the bone called the ‘epiphyseal plate’ – a growth region in the bone.

To do this, the needle is positioned straight onto the bone. When the tip of the needle contacts the bone, a hard stop indicates that the needle is in the right place. There should be about 5 mm of the needle visible above the skin. This ensures that the needle is long enough to penetrate the inner part of the bone where marrow is located. If need be, a longer needle or a place where there is less skin and soft tissue covering the bone can be chosen. This could be required in people with obesity where the bone is not very deep under the skin.

How can the doctor make sure the needle is correctly placed? They do it by making sure the needle is stable in the bone. They also try to gently take out some marrow or push in some sterile salt water (saline). Good flows of injected fluids indicate proper placement of the needle. However, sometimes they aren’t able to get any marrow out, but that doesn’t automatically mean that the needle is not in the right place. Even if this happens, the doctor will continue with pushing in the saline and try to take out some marrow again.

After the needle is put in, the doctor will flush it out with 5 to 10 ccs of saline for adults or 2 to 5 ml for babies and children. This might hurt a lot. A local anesthetic called Lidocaine might be injected to reduce the pain. Doctors need to wait about 2 minutes for Lidocaine to work before doing the flush.

Once the needle is safely in the bone, it needs to be held firm. This is to prevent it from unexpectedly coming out or bending. This is done with each device used but is critically important to keep the needle straight and secure.

The healthcare team makes a note of when the needle was put in to make sure it stays in for less than 24 hours. When other better ways are available for giving the patient fluids or medications, this needle is taken out and the place is bandaged.

Possible Complications of Intraosseous Vascular Access

If the needle doesn’t go deep enough into the bone during an injection, it won’t be possible to flush it with saline. Going deeper with the needle will solve this problem.

Sometimes, the fluid can leak out into the surrounding tissue instead of going into the bone. This can happen if the needle goes through the back of the bone, if the injection is done at a site where the bone was previously injured or had recent surgery, or if the needle is injected into a fracture. Leaking fluid can cause a condition called compartment syndrome and other complications, depending on what substance is being injected.

For children, it’s important to avoid injecting the needle near the growth plate, or epiphyseal plate, in their bones. This can prevent the growth plate from dying or getting damaged.

There are also other potential complications. These can include a fractured bone, skin infection, bone infection, fat particles blocking blood flow, or not being able to take out a needle that has bent inside the bone. A bent needle might need to be surgically removed.

What Else Should I Know About Intraosseous Vascular Access?

If you need immediate medical attention and doctors need to get medications or fluids into your body quickly, they normally use an intravenous (IV) line. But occasionally, getting IV access might be difficult or not possible. In such urgent cases, an alternative approach called intraosseous (IO) access is used. Here, a needle is inserted directly into your bone marrow (most often the leg bone). This method is simple, fast, and reliable, and can also be used by paramedics in an emergency even before reaching the hospital.

Blood taken directly from your bone marrow can also be used for laboratory tests. Although studies have suggested varying degrees of accuracy for these tests, especially compared to tests done on blood taken from a vein (venous blood), more human studies are needed to confirm these findings. If and when vein access is achieved, the doctors will usually repeat the lab tests to ensure the results are correct.

Tests done on animals have shown that levels of certain substances in the blood like sodium, creatinine, creatinine kinase, and hematocrit (the proportion of your blood that is made up of red blood cells) remain the same whether the blood is taken from a bone or a vein. However, levels of glucose, lactate, and particularly potassium might differ. One important thing to note is that blood type can be accurately identified even after a blood transfusion has been given through an IO device, which means if blood is urgently needed, it can be safely given in this way.

Frequently asked questions

1. How does the intraosseous vascular access procedure work? 2. What are the different sites where the needle can be inserted for intraosseous access? 3. What are the potential complications or risks associated with intraosseous vascular access? 4. How long can the intraosseous needle stay in place? 5. How does the accuracy of laboratory tests done on blood taken from the bone compare to tests done on blood taken from a vein?

Intraosseous vascular access allows doctors to quickly administer treatment or medication in emergency situations by accessing the inside of a bone. The preferred sites for adults are the upper arm bone, shin bone, or breastbone, while for babies and young children, the ends of the thigh bone and shin bone are used. Doctors carefully measure and feel the edges of the bone to ensure proper needle insertion.

You may need Intraosseous Vascular Access if a doctor is unable to access your veins properly for certain treatments or procedures. This could be due to reasons such as having a broken bone, a burn or infection in the area, conditions like Osteogenesis Imperfecta or Osteoporosis, previous unsuccessful attempts at vein access, or recent orthopedic surgery. Intraosseous Vascular Access allows the doctor to access your vascular system by inserting a needle directly into the bone marrow, providing an alternative route for medication or fluid administration.

You should not get Intraosseous Vascular Access if you have a broken bone, a burn in the area where the doctor needs to access the vein, an infection at the access site, Osteogenesis Imperfecta, Osteoporosis, a recent unsuccessful attempt to access the vein, or if you recently had orthopedic surgery.

To prepare for Intraosseous Vascular Access, the patient should be aware that this method is used when it is difficult or time-consuming to insert a needle into a vein. The preferred spots for adult patients are the upper arm bone, shin bone, or breastbone, while for babies and young children, the ends of the thigh bone and shin bone are the best spots. The patient should also be aware that anything that can be given through an IV can be given through IO vascular access, but it should not be used for more than 24 hours due to an increased risk of complications.

The complications of Intraosseous Vascular Access include the needle not going deep enough into the bone, fluid leaking into surrounding tissue instead of going into the bone, compartment syndrome, injecting near the growth plate in children, fractured bone, skin infection, bone infection, fat particles blocking blood flow, and difficulty in removing a bent needle.

Symptoms that require Intraosseous Vascular Access include difficulty finding a vein to take blood, urgency to access a vein in emergency situations, and the need for a quicker way to access a vein for special imaging tests or injecting contrast dye into the bloodstream.

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