Intraosseous Infusion
When rapid venous infusion is difficult or impossible, intraosseous infusion allows delivery of fluids, medications, or whole blood into the bone marrow. Performed on infants and children, this technique is used in such emergencies as cardiopulmonary arrest, circulatory collapse, hypokalemia from traumatic injury or dehydration, status epilepticus, status asthmaticus, burns, near-drowning, and overwhelming sepsis.
Any drug that can be given I.V. can be given by intraosseous infusion with comparable absorption and effectiveness. Intraosseous infusion has been used as an acceptable alternative for infants and children.
Intraosseous infusion is commonly undertaken at the anterior surface of the tibia. Alternative sites include the iliac crest, spinous process and, rarely, the upper anterior portion of the sternum. Only personnel trained in this procedure should perform it. Usually, a nurse assists. (See Understanding intraosseous infusion.)
This procedure is contraindicated in patients with osteogenesis imperfecta, osteopetrosis, and ipsilateral fracture because of the potential for subcutaneous extravasation. Infusion through an area with cellulitis or an infected burn increases the risk of infection.
Equipment
Bone marrow biopsy needle or specially designed intraosseous infusion needle (cannula and obturator) • povidone-iodine pads • sterile gauze pads • sterile gloves • sterile drape • bone marrow set • heparin flush solution • I.V. fluids and tubing • 1% lidocaine • 3- or 5-ml syringe • tape.
Preparation of equipment
Prepare I.V. fluids and tubing as ordered.
Implementation
If the patient is conscious, explain the procedure to allay his fears and promote his cooperation. Ensure that the patient or a responsible family member understands the procedure and signs a consent form.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Check the patient's history for hypersensitivity to the local anesthetic. If the patient isn't an infant, tell him which bone site will be infused. Inform him that he will receive a local anesthetic and will feel pressure from needle insertion.
Wash your hands.
Provide a sedative, if ordered, before the procedure.
Position the patient based on the selected puncture site.
Using sterile technique, the physician cleans the puncture site with a povidone-iodine pad and allows it to dry. He then covers the area with a sterile drape.
Using sterile technique, hand the physician the 3- or 5-ml syringe with 1% lidocaineso that he can anesthetize the infusion site.
The physician inserts the infusion needle through the skin and into the bone at an angle of 10 to 15 degrees from vertical. He advances it with a forward and backward rotary motion through the periosteum until it penetrates the marrow cavity. The needle should “give†suddenly as it enters the marrow and stand erect when released.
Then the physician removes the obturator from the needle and attaches a 5-ml syringe. He aspirates some bone marrow to confirm needle placement.
The physician replaces this syringe with a syringe containing 5 ml of heparin flush solution and flushes the cannula to confirm needle placement and clear the cannula of clots and bone particles.
Next, the physician removes the syringe of flush solution and attaches I.V. tubing to the cannula to allow infusion of medications and I.V. fluids.
Put on sterile gloves.
Clean the infusion site with povidone-iodine pads, and then secure the site with tape and a sterile gauze dressing.
Monitor vital signs and check the infusion site for bleeding and extravasation.
Special considerations
Facility policy may vary as to securing the site and dressing materials used. Some facilities may use transport dressings. Check your facility's policy and procedure manual.
Intraosseous infusion should be discontinued as soon as conventional vascular access is established (within 2 to 4 hours, if possible). Prolonged infusion significantly increases the risk of infection.
After the needle has been removed, place a sterile dressing over the injection site, and apply firm pressure to the site for 5 minutes.
Intraosseous flow rates are determined by needle size and flow through the bone marrow. Fluids should flow freely if needle placement is correct. Normal saline solution has been given intraosseously at a rate of 600 ml/minute and up to 2,500 ml/hour when delivered under pressure of 300 mm Hg through a 13G needle.
Complications
Common complications include extravasation of fluid into subcutaneous tissue, resulting from incorrect needle placement; subperiosteal effusion, resulting from failure of fluid to enter the marrow space; and clotting in the needle, resulting from delayed infusion or failure to flush the needle after placement. Other complications include subcutaneous abscess, osteomyelitis, and epiphyseal injury.
Documentation
Record the time, date, location, and patient's tolerance of the procedure. Document the amount of fluid infused on the input and output record.
Any drug that can be given I.V. can be given by intraosseous infusion with comparable absorption and effectiveness. Intraosseous infusion has been used as an acceptable alternative for infants and children.
Intraosseous infusion is commonly undertaken at the anterior surface of the tibia. Alternative sites include the iliac crest, spinous process and, rarely, the upper anterior portion of the sternum. Only personnel trained in this procedure should perform it. Usually, a nurse assists. (See Understanding intraosseous infusion.)
This procedure is contraindicated in patients with osteogenesis imperfecta, osteopetrosis, and ipsilateral fracture because of the potential for subcutaneous extravasation. Infusion through an area with cellulitis or an infected burn increases the risk of infection.
Equipment
Bone marrow biopsy needle or specially designed intraosseous infusion needle (cannula and obturator) • povidone-iodine pads • sterile gauze pads • sterile gloves • sterile drape • bone marrow set • heparin flush solution • I.V. fluids and tubing • 1% lidocaine • 3- or 5-ml syringe • tape.
Preparation of equipment
Prepare I.V. fluids and tubing as ordered.
Implementation
If the patient is conscious, explain the procedure to allay his fears and promote his cooperation. Ensure that the patient or a responsible family member understands the procedure and signs a consent form.
If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.
Check the patient's history for hypersensitivity to the local anesthetic. If the patient isn't an infant, tell him which bone site will be infused. Inform him that he will receive a local anesthetic and will feel pressure from needle insertion.
Wash your hands.
Provide a sedative, if ordered, before the procedure.
Position the patient based on the selected puncture site.
Using sterile technique, the physician cleans the puncture site with a povidone-iodine pad and allows it to dry. He then covers the area with a sterile drape.
Using sterile technique, hand the physician the 3- or 5-ml syringe with 1% lidocaineso that he can anesthetize the infusion site.
The physician inserts the infusion needle through the skin and into the bone at an angle of 10 to 15 degrees from vertical. He advances it with a forward and backward rotary motion through the periosteum until it penetrates the marrow cavity. The needle should “give†suddenly as it enters the marrow and stand erect when released.
Then the physician removes the obturator from the needle and attaches a 5-ml syringe. He aspirates some bone marrow to confirm needle placement.
The physician replaces this syringe with a syringe containing 5 ml of heparin flush solution and flushes the cannula to confirm needle placement and clear the cannula of clots and bone particles.
Next, the physician removes the syringe of flush solution and attaches I.V. tubing to the cannula to allow infusion of medications and I.V. fluids.
Put on sterile gloves.
Clean the infusion site with povidone-iodine pads, and then secure the site with tape and a sterile gauze dressing.
Monitor vital signs and check the infusion site for bleeding and extravasation.
Special considerations
Facility policy may vary as to securing the site and dressing materials used. Some facilities may use transport dressings. Check your facility's policy and procedure manual.
Intraosseous infusion should be discontinued as soon as conventional vascular access is established (within 2 to 4 hours, if possible). Prolonged infusion significantly increases the risk of infection.
After the needle has been removed, place a sterile dressing over the injection site, and apply firm pressure to the site for 5 minutes.
Intraosseous flow rates are determined by needle size and flow through the bone marrow. Fluids should flow freely if needle placement is correct. Normal saline solution has been given intraosseously at a rate of 600 ml/minute and up to 2,500 ml/hour when delivered under pressure of 300 mm Hg through a 13G needle.
Complications
Common complications include extravasation of fluid into subcutaneous tissue, resulting from incorrect needle placement; subperiosteal effusion, resulting from failure of fluid to enter the marrow space; and clotting in the needle, resulting from delayed infusion or failure to flush the needle after placement. Other complications include subcutaneous abscess, osteomyelitis, and epiphyseal injury.
Documentation
Record the time, date, location, and patient's tolerance of the procedure. Document the amount of fluid infused on the input and output record.
