What are the alternatives for administering medication when an intravenous (IV) line cannot be accessed?

Alternatives for Medication Administration When IV Access Cannot Be Obtained

When intravenous access cannot be established, intraosseous (IO) access is the preferred alternative route for medication administration in emergency situations, as it provides drug delivery comparable to peripheral IV access and can be established rapidly without interrupting critical interventions. 1

Hierarchical Approach to Alternative Access Routes

First-Line Alternative: Intraosseous (IO) Access

It is reasonable to establish IO access if IV access is not readily available, particularly in emergency and resuscitation scenarios. 1

• IO cannulation provides access to a noncollapsible venous plexus, enabling drug delivery similar to peripheral venous access at comparable doses. 1
• Preferred insertion sites are the tibia (2 cm distal to tibial tuberosity, 1 cm medial to tibial plateau) and the humerus. 1
• IO access is faster to establish than central venous access and can be used for resuscitation fluids, drugs, and blood sampling. 1
• Commercially available manual and automated devices facilitate IO placement in all age groups. 1
• Success is confirmed by: aspiration of bone marrow, saline flush without extravasation, needle support by bone cortex, and infusion under gravity alone. 1
• Devices should be removed as soon as suitable IV access is achieved, ideally within 24 hours, to minimize complications including fracture, extravasation, osteomyelitis, infection, compartment syndrome, and growth plate injury. 1

Second-Line Alternative: Ultrasound-Guided Peripheral IV Access

For non-emergent situations or when IO access is not appropriate, ultrasound-guided peripheral IV placement should be attempted before proceeding to central access. 1

• Real-time ultrasound guidance significantly increases first-pass success rates (90% vs 18% with standard technique) and reduces procedural time in difficult-access patients. 2
• Emergency nurses achieved 87% success rates with ultrasound-guided peripheral IV placement in difficult-access patients after brief training. 3
• Ultrasound guidance reduces the perceived difficulty of IV placement and decreases the number of attempts required. 4
• Midline catheters (10-20 cm long) inserted into upper arm veins with ultrasound guidance provide short to medium-term access (1-4 weeks) but should not be used for medications requiring central venous administration. 1

Third-Line Alternative: Central Venous Access

Appropriately trained providers may consider central line placement (internal jugular or subclavian) when other options have failed, unless contraindications exist. 1

• Central lines provide higher peak drug concentrations and shorter circulation times compared to peripheral IV catheters. 1
• Real-time ultrasound guidance should be used for all central venous catheter insertions, regardless of provider experience level, to reduce mechanical and infectious complications. 5
• Central line placement can interrupt CPR in cardiac arrest situations, which is a significant disadvantage. 1

Alternative Routes for Specific Medications

Intramuscular (IM) Administration

• IM administration is less preferred than IV/IO routes because it does not allow for medication titration and is painful at delivery. 1
• For acute agitation without IV access, IM lorazepam (2.5-5 mg every 2-4 hours) or IM haloperidol (0.5-1 mg for elderly, 1.5-3 mg for severely distressed patients) can be used. 6
• Diazepam IM is not recommended due to erratic absorption. 6

Intranasal/Transmucosal Routes

• Alternative routes including intranasal, transdermal, and inhaled medications offer rapid relief comparable to IV opioids for pain management. 1
• Intranasal delivery demonstrates rapid onset but may be less tolerated due to nasal mucosa burning. 1
• Drug delivery is enhanced with atomizers that distribute medication evenly to mucous membranes. 1

Rectal Administration

• Rectal diazepam can be administered when IM options are not feasible. 6

Endotracheal Route (Least Preferred)

Endotracheal drug administration is no longer recommended as a preferred route because it results in lower blood concentrations and unpredictable pharmacologic effects compared to IV/IO routes. 1

• Only lidocaine, epinephrine, atropine, naloxone, and vasopressin are absorbed via the trachea; there are no data for endotracheal amiodarone. 1
• Lower epinephrine concentrations from endotracheal delivery may produce detrimental β-adrenergic vasodilation effects, reducing coronary perfusion pressure. 1
• In one study, 5% of patients receiving IV drugs during cardiac arrest survived to discharge, but no patients survived in the endotracheal drug group. 1

Critical Pitfalls to Avoid

• Never use static ultrasound alone to mark needle insertion sites; always use real-time (dynamic) ultrasound guidance. 5
• Avoid routine peripheral cannula changes at 72-96 hours, as this is not advocated. 1
• Do not administer peripheral IV fluids with high osmolality (>500 mOsm/L), low pH (<5), or high pH (>9). 1
• When administering drugs via peripheral IV during resuscitation, follow with a 20-mL bolus of IV fluid and briefly elevate the extremity to facilitate central circulation delivery. 1
• Respiratory monitoring is crucial when administering benzodiazepines via any route, with reversal agents (flumazenil) readily available. 6
• Combining multiple CNS depressants increases respiratory depression risk and should be avoided. 6