What are the indications for intraosseous (IO) vascular access?

Indications for Intraosseous (IO) Vascular Access

Intraosseous access should be used as a rapid first-line vascular access method in emergency situations when peripheral IV access is difficult or cannot be quickly established, particularly in cardiac arrest, septic shock, and critically ill patients requiring immediate resuscitation. 1

Primary Emergency Indications

Cardiac Arrest

• IO access is the preferred initial vascular access route in cardiac arrest when peripheral IV cannot be rapidly obtained (Class I recommendation). 1
• This applies to both pediatric and adult patients in cardiac arrest, including traumatic arrest, drowning, and sudden infant death syndrome (SIDS). 2
• Success rates exceed 95% with modern devices like the EZ-IO, compared to only 50-55% with older manual techniques. 2, 3

Sepsis and Septic Shock

• IO access can be quickly and reliably established (even in adults) to rapidly administer initial doses of antimicrobials when vascular access is limited. 1
• This is critical when prompt IV infusion of antimicrobials is a priority alongside fluid resuscitation, as delays in appropriate antimicrobial therapy substantially increase morbidity and mortality in septic shock. 1

Difficult Peripheral Vascular Access

• IO should be considered immediately after 2-3 failed peripheral IV attempts rather than continuing repeated blind attempts. 4
• IO access is faster than central venous catheterization (2.0 vs 8.0 minutes) with higher first-attempt success rates (85% vs 60%) in adults with inaccessible peripheral veins. 5
• All acute care clinicians should be familiar with IO techniques and have ready access to devices. 1

Additional Clinical Scenarios

Pediatric Emergencies

• IO is recommended for children ≤6 years of age when conventional vascular access cannot be timely established. 6
• Nearly one-third of IO insertions occur in patients younger than 2 years, where peripheral access is particularly challenging. 2
• All emergency drugs and infusion fluids approved for IV use can be safely administered via IO (except hypertonic solutions). 6

Other Critical Conditions

• Multi-trauma patients requiring immediate resuscitation. 2
• Seizures/status epilepticus requiring urgent medication administration. 2
• Respiratory failure requiring immediate intervention. 2

Technical Considerations

Preferred Insertion Sites

• Tibia: 2 cm distal to tibial tuberosity and 1 cm medial to tibial plateau. 1
• Humerus: Alternative preferred site. 1
• Avoid epiphyseal growth plates in children. 1

Confirmation of Successful Placement

• Aspiration of bone marrow (painful in awake patients). 1
• Saline flush without extravasation. 1
• Needle support by bone cortex. 1
• Infusion under gravity alone. 1

Critical Pitfalls to Avoid

Timing of Removal

• Devices should be removed as soon as suitable IV access is achieved, ideally within 24 hours of placement. 1
• Replace IO access within 2 hours when possible to avoid complications like osteomyelitis. 6

Complications (Rare but Important)

• Fracture, extravasation, osteomyelitis, infection, compartment syndrome, growth plate injury, and pressure necrosis. 1
• No serious complications like osteomyelitis were documented in a 7-year HEMS study of 78 insertions. 2

Drug Administration Considerations

• All IV medications can be administered IO, including epinephrine, adenosine, fluids, blood products, and catecholamines. 1
• Use manual pressure or infusion pump for viscous drugs or rapid fluid boluses. 1
• Follow each medication with saline flush to promote central circulation entry. 1
• Acid-base analysis is inaccurate after sodium bicarbonate administration via IO. 1

Organizational Requirements

Hospitals must establish systems ensuring 24/7 availability of personnel skilled in IO techniques, with high-resolution ultrasound devices and dedicated "difficult access" equipment readily available. 4