Paediatric Acute care Guidelines PMH Emergency Department

Pre-Procedure

  • The IO space functions as a non-collapsible vein
  • The emissary veins of the IO space absorb all parenteral medication, crystalloid fluids and/or blood products – which move quickly into the central circulation
  • Complications are minor and infrequent
  • Blood taken from the IO needle can be sent for most laboratory investigations except full blood count
  • It is possible to do group and hold/cross match, blood cultures and blood glucose level
  • Biochemical results may be slightly inaccurate
  • Ensure all blood sent to lab are clearly labelled IO blood sample
  • All medications and fluids which would normally be given intravenously can be given via intraosseous route

Indications

  • Cardiopulmonary arrest
  • Any critical emergency when a peripheral venous cannulation site is unobtainable within 90 seconds
  • Oral, transmucosal, intramuscular or inhalation routes are not adequate to meet the patients needs for fluids and/or medications

Contraindications

  • Fractures:  do not place an IO below a fracture site, use the other limb
  • Open injury:  avoid placement of an IO below any open injury on an extremity, use other limb
  • Infection at potential site:  use alternative site

Preparation

Equipment

For Manual Intraosseous Needle Insertion For Mechanised Intraosseous Needle Insertion
  • There are a range of commercially IO needles available
    • PMH ED has 3.0 cm in length only available in Resus
  • Alcohol swabs or Povidone-Iodine solution
  • 10ml syringe for aspiration
  • 10ml syringe with 0.9% saline for flush
  • 3 way extension tap
  • A pair of clean gloves
  • IO insertion device
  • Use the 15mm needle (pink) for 3 – 40 kg patient                           
  • Use the 25mm needle (blue) for > 40 kg patient
  • Alcohol swab or Povidone-Iodine solution
  • 10ml syringe for aspiration
  • 10ml syringe with 0.9% saline for flush
  • 3 way extension tap
  • A pair of clean gloves
  • EZ-Connect connection (comes with needle)

 

Procedure

Positioning and technique

Identification Of Entry Site
  • The best site in children is the anteriomedial aspect of the tibia. 2-3cm below the tibia tuberosity, anterior medial side

IO tibia 

 

 

 

  • Alternative sites are:
    • Distal femur – 2-3cm above the patella, in the midline

IO Femur 

 

 

 

    • Distal tibia – above the medial malleolus at the ankle

Procedure for Manual Intraosseous Needle Insertion

Procedure for Mechanised Intraosseeous Needle Insertion
  • Use aseptic technique
  • Clean skin at chosen site, allow to dry. Stabilise the leg.
  • Infiltrate with 1% lignocaine if child is conscious and time permits
  • Insert the IO at 90° angle to the skin, passing deep into the bone via a ‘twisting’ motion
  • A “pop” may be felt as the needle passes through the bone cortex into the marrow cavity
  • Remove the inner stylet from the needle
  • Confirm the position and proceed with infusion
  • Observe for complications
  • Use aseptic technique
  • Clean skin at chosen site, allow to dry. Stabilise the leg.
  • Infiltrate with 1% lignocaine if child is conscious and time permits
  • Attach compatible IO needle to end of device (magnetic attachment).  Pierce the skin with the IO needle until it touches the bone surface with a gentle push.
  • Check that at least one black line is visible on the needle. If no black line visible, the needle may not be long enough to reach the medullary space.
  • Squeeze the trigger, guiding the needle into the bone
  • You may feel a “give” as the needle enters the bone marrow cavity – at this point release the trigger
  • Detach the needle from the device
  • Remove the inner stylet from the needle
  • Confirm position and proceed with infusion
  • Observe for complications

 

Post-Procedure

Confirm success

By:

  • Aspirating marrow contents
  • Infusing 10ml of 0.9% Saline without significant resistance

Once position confirmed:

  • Attach a 3 way extension tap
  • Infuse injections through the 3 way tap side port
  • Connect IV fluids through the other 3 way port
  • IV fluids may need to be infused under pressure or bloused via a 20ml syringe
  • Secure IO in place
  • Observe for complications

Complications

  • Extravasation of the IO needle
  • Dislodgement
  • Compartment syndrome
  • Bone infections
  • Bone fracture

Aftercare

  • Do not use IO access for greater than 24 hours
  • To Remove IO:
    • Remove extension set from needle hub and attach a 5-10ml sterile syringe with standard luer lock to act as a handle and cap the open IO port
    • Grasp syringe and continuously rotated clockwise while gently pulling the needle out
    • Maintain 90° angle to the bone
    • Do not rock or bend the needle during removal

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References

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