A physician, registered nurse (RN), paramedic, or other healthcare professional trained in the insertion technique may perform intraosseous (IO) insertion. Who can perform IO insertion may vary according to local and state guidelines.
A healthcare prescriber orders medications.
Principles of pharmacologic management (see Chapter 6) are followed.
Medication administration guidelines are followed, including correct patient, medication, dose, route, time, and approach to child.
IO infusion is indicated for short-term fluid and drug therapy until intravenous (IV) access can be established.
IO access should be initiated after three unsuccessful attempts or 90 seconds of IV access attempts in emergency situations. Vascular access may be accomplished through the IO route without first attempting IV access.
IO access may be performed in children of any age. In newborns, IO access should be established if umbilical venous access cannot be established. Preferred site is the flat portion of the proximal tibia, about 1 to 3 cm below and slightly medially from the tibial tuberosity. After age 5 or 6 years, the bony cortex may be difficult to penetrate and alternate IO sites may be needed, such as the distal tibia, sternum, or other bones.
Continue efforts to establish IV access after obtaining IO access.
IO sites should not be used for access longer than 24 hours. Discontinue the IO access as soon as a suitable vascular access route is established, or the child is able to tolerate oral intake.
IO needle
Children younger than 18 months old: 18- to 20-gauge needle (or a spinal needle may be used)
Older children: 13-, 15-, or 18-gauge needle
Battery-powered IO insertion device, if one is available and approved by the institution
Antiseptic solution (chlorhexidine or povidoneiodine)
Lidocaine 1%, syringe, and 25-gauge needle
Sterile gauze
Nonsterile gloves
Sterile normal saline (10 mL) for injection (preservative-free in neonates)
Short T-infusion IV primer set
IV tubing and fluid
Sandbag, folded towel, or IV bag to support the child’s leg
Gauze pads (4 × 4)
Tape
Prescribed medication and fluids
Syringe
Antiseptic wipe
Nonsterile gloves
Normal saline (0.9% sodium chloride)
Assess the child’s heart rate, respiratory rate, blood pressure, temperature, and neurovascular status of the extremity to obtain baseline values.
Assess the child’s medical history and site for the following contraindications to IO:
Presence of osteogenesis imperfecta, osteopetrosis, trauma, or fracture of the extremity (which may result in fluid infiltration into the subcutaneous tissue)
Presence of cellulitis, burns, or skin infections over the site (which increase the risk for infectious complications)
Previous attempts at IO insertion in the same bone
Assess for drug allergies; if present, notify healthcare prescriber. After initial resuscitation, label the
child’s record and apply identification band indicating allergies.
Have a support person (e.g., social services, clergy, RN, psychologist) available for the family during resuscitation and stabilization of the child. If support person cannot provide explanations of medical care, a nurse or physician should explain procedure to family as soon as possible.
If the child is aware, explain the procedure to the child as appropriate to the child’s cognitive level.
Measure the leg circumference just below the knee to obtain baseline to evaluate potential infiltration.
PROCEDUREInsertion of Intraosseous Needle
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