Is intraosseous (IO) the preferred route for volume resuscitation in small children?

Intraosseous Access is the Preferred Route for Volume Resuscitation in Small Children When IV Access Cannot Be Rapidly Established

Intraosseous (IO) access should be considered early in the care of critically ill small children requiring volume resuscitation when intravenous access cannot be rapidly established within 5 minutes of attempting. 1

Evidence-Based Rationale

The American Heart Association (AHA) guidelines clearly state that IO access is a rapid, safe, effective, and acceptable route for vascular access in children during emergencies, particularly in cardiac arrest situations 1. This recommendation is supported by international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science 1.

Advantages of IO Access in Small Children:

• Can be quickly established with minimal complications by providers with varied training levels
• Allows administration of all intravenous medications including epinephrine, adenosine, fluids, blood products, and catecholamines
• Onset of action and drug levels for most drugs are comparable to venous administration
• Can be used to obtain blood samples for analysis

Clinical Decision Algorithm

1. First attempt: Try to establish peripheral IV access (if patient condition allows)

   • Maximum attempt time: 5 minutes 2
   • If successful, use for fluid resuscitation

2. If peripheral IV unsuccessful within 5 minutes:

   • Immediately proceed to IO access 1
   • Preferred site: Medial aspect of proximal tibia, just below tibial tuberosity 3
   • Use commercially available IO needle appropriate for child's size

3. After resuscitation:

   • Replace IO access with conventional vascular access within 2 hours to avoid complications like osteomyelitis 3

Efficacy and Safety Considerations

Research demonstrates that IO access is highly effective for volume resuscitation:

• IO access can be secured in all cases within 5 minutes, while IV access fails in approximately 33% of severely dehydrated children within the same timeframe 2
• Mean time for IO cannulation (67 ± 7 seconds) is significantly faster than IV cannulation (129 ± 13 seconds) 2
• Fluid infusion through IO is equally effective as IV in stabilizing vital signs and normalizing laboratory abnormalities 2

Special Considerations

• All emergency drugs and infusion fluids for intravenous usage can be safely administered via the IO route (except hypertonic solutions) 3
• No need to adjust drug dosage compared to the intravenous route 3
• Use manual pressure or an infusion pump to administer viscous drugs or rapid fluid boluses 1
• Follow each medication with a saline flush to promote entry into central circulation 1

Caveats and Pitfalls

1. Limited duration: IO access should be replaced within 2 hours by conventional vascular access to avoid complications 3

2. Age considerations: While IO is recommended for children ≤6 years of age 3, the technique has been successfully used in children up to 10 years 4

3. Setting-specific considerations:

   • In neonatal resuscitation in delivery rooms, umbilical venous access is preferred over IO access 1
   • Outside delivery room settings, either umbilical venous access or IO access may be used for neonatal resuscitation 1

4. Training requirements: Successful application requires immediate access to necessary equipment, intensive education, continuous training, and clear guidelines 5

IO access has been established as a rapid, safe, and simple method for obtaining short-term vascular access in critically ill and injured children and deserves primary consideration when venous access is not rapidly obtainable in emergency situations requiring volume resuscitation 4.