What are the guidelines for administering adenosine through tibial intraosseous (IO) access?

From the Guidelines

Adenosine can be administered through tibial intraosseous (IO) access using the same dosing as peripheral IV administration: 6 mg rapid push for the first dose, followed by 12 mg if needed for a second or third dose. When administering through IO access, the medication should be followed by a 20 mL saline flush to ensure complete delivery into the circulation. The administration technique should include rapid push (over 1-2 seconds) followed by the flush, as adenosine has an extremely short half-life of less than 10 seconds 1. For tibial IO specifically, providers should be aware that the medication may take slightly longer to reach the central circulation compared to humeral IO or central venous access, potentially affecting onset of action.

The IO needle must be confirmed as properly placed with aspiration of bone marrow or free flow of fluids before administration. Adenosine works by temporarily blocking AV nodal conduction to terminate supraventricular tachycardias, and its rapid degradation in the bloodstream necessitates the quick administration technique. Patients should be monitored for transient side effects including flushing, chest pain, dyspnea, and brief asystole, which typically resolve within seconds due to the medication's short half-life. Key considerations for administration include:

• Initial dose: 6 mg rapid IV bolus
• Subsequent doses: 12 mg rapid IV bolus if no response within 1-2 minutes
• Administration technique: rapid push over 1-2 seconds, followed by a 20 mL saline flush
• Monitoring: for transient side effects and potential recurrence of supraventricular tachycardia. According to the most recent guidelines, adenosine is safe and effective for the treatment of supraventricular tachycardia, with a high success rate and minimal side effects 1.

From the Research

Guidelines for Administering Adenosine through Tibial Intraosseous (IO) Access

• The American Heart Association and the European Resuscitation Council recommend intraosseous (IO) access for administering resuscitative drugs and fluids when intravenous (IV) access cannot be rapidly or easily obtained 2.
• There is evidence that tibial intraosseous access can be used for administering iodinated contrast for computed tomography angiograms 3.
• The optimal location for tibial intraosseous access is 0.5 cm below the tibial tuberosity in the midline of the medial surface, with a recommended standard length for the intraosseous cannula of 17 mm, excluding skin thickness 4.
• However, the use of intraosseous infusion for adenosine delivery in the treatment of supraventricular tachycardia has been found to be unreliable 5.

Considerations for Tibial IO Access

• Tibial intraosseous access has been compared to peripheral intravenous access and humeral intraosseous access in out-of-hospital cardiac arrest, with lower odds of return of spontaneous circulation at emergency department arrival associated with tibial intraosseous access 6.
• The effectiveness of tibial intraosseous access may depend on various factors, including the patient's condition and the specific medication being administered.

Administration of Adenosine via Tibial IO

• There is limited evidence to support the use of tibial intraosseous access for administering adenosine, and its effectiveness for this purpose is uncertain 5.
• Further research is needed to determine the safety and efficacy of administering adenosine through tibial intraosseous access.