1. Intraosseous needle insertion
Dr. Mohamed Haseen Basha
Assistant professor ( Paediatrics)
Faculty of Medicine
Al Maarefa College of Science and Technology

2. Indications
Obtain emergency access in children during life-threatening situations. cardiopulmonary arrest, shock, burns, and life-threatening status epilepticus.
IO line can be used to infuse medications, blood products, or fluids.

3. Contraindications Osteogenesis imperfect Osteoporosis
Clotting disorders.
Fractures in the target bone
Previous orthopaedic surgery near the insertion site
Previous IO insertion in the target bone within the preceding 48 hours
Infection at the insertion site

4. Anatomy
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.
The IO needle should be removed once adequate vascular access has been established.

6. Sites
Proximal Tibia
Anteromedial surface of the proximal tibia, 2 cm below and 1 to 2 cm medial to the tibial tuberosity on the flat part of the bone
Distal Tibia
Medial surface of the distal tibia 1 to 2 cm above the medial malleolus (may be a more effective site in older children)
Distal femur
3 cm above the lateral condyle in the midline

8. Equipment required sterile gloves and gown basic dressing pack
antiseptic to prepare the skin
rigid needle with an inner stylet (for patients < 18 months an lumbar puncture needle can be used)
syringe with NaCl 0.9% flush
routine IV line tubing set-up and tape

9. procedure Immobilize the extremity. Prepare the site with antiseptic.
Consider need to use local anaesthetic( 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.

10. 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.

11. Three indicators of successful insertion
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.

12. 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.

13. Absorption
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.

15. complications fracture of the target bone infection extravasation
subperiosteal infusion
embolism
compartment syndrome
pain on use
dislodgement
skin necrosis