What is radial intraosseous (IO) access?

From the Guidelines

Radial IO access is not recommended as a primary site for intraosseous access due to the risk of complications and the availability of alternative sites with lower risk profiles. The most recent and highest quality study, 1, published in 2016, recommends the tibia and humerus as preferred sites for intraosseous access.

Key Points to Consider

• The tibia and humerus are preferred sites for intraosseous access due to their relatively low risk of complications and high success rates.
• The insertion site for the tibia is 2 cm distal to the tibial tuberosity and 1 cm medial to the tibial plateau, with care needed to avoid the epiphyseal growth plate in children.
• Success of intraosseous access is evident by aspiration of bone marrow, saline flush with no extravasation, support of the needle by the bone cortex, and infusion under gravity alone.
• Complications of intraosseous access include fracture, extravasation, osteomyelitis, infection, compartment syndrome, growth plate injury, and pressure necrosis of the skin.
• Devices should be removed as soon as suitable IV access is achieved, ideally within 24 hours of placement, to minimize the risk of infection and other complications.

Recommendations for Intraosseous Access

• Use the proximal humerus or proximal tibia as primary sites for intraosseous access, with the distal tibia as an alternative.
• For adults, use an EZ-IO 15mm needle for most patients, 25mm for larger patients, and 45mm for the humeral site in obese patients.
• For children, use a 15mm needle.
• After confirming placement, flush with 10mL saline (5mL for children) to promote entry into the central circulation.
• All medications and fluids that can be given IV can be administered via IO, with similar onset times, as stated in 1.

From the Research

Radial IO Access

• Radial intraosseous (IO) access is a reliable alternative to intravenous vascular access, especially in emergency situations where intravenous access is difficult or impossible 2.
• The use of ultrasound guidance for central venous access, including radial access, has been shown to decrease the number of needle puncture attempts, complications, and failure rates 3.
• Real-time ultrasound guidance is recommended for radial arterial access, as it has been shown to increase first-pass success rates, reduce the time to successful cannulation, and reduce the risk of complications compared to landmark-based techniques 4.

Techniques and Recommendations

• The EZ-IO needle driver has been shown to be an efficient alternative for establishing immediate out-of-hospital vascular access, including radial IO access 2.
• Point-of-care colour Doppler ultrasound can be used to confirm intraosseous needle placement, including radial IO access, and detect extraosseous flow in incorrectly positioned needles 5.
• Primary healthcare physicians should acquire the skill of intraosseous line insertion, including radial IO access, as it is a lifesaving procedure 6.

Equipment and Training

• Operators should be familiar with the equipment and techniques used for radial IO access, including the use of ultrasound guidance and automated intraosseous devices 4, 2.
• Training programs for radial IO access should include a combination of simulation-based practice, supervised insertion on patients, and evaluation by an expert operator 4.
• Competency assessments for radial IO access should include formal evaluation of knowledge and technical skills using standardized assessment tools 4.