From the Guidelines
If peripheral intravenous (IV) access cannot be obtained, the next step should be to consider intra-osseous (IO) access, as it is a rapid and effective alternative for emergency situations, allowing for the administration of resuscitation fluids and drugs. This approach is supported by the Association of Anaesthetists of Great Britain and Ireland's guidelines on safe vascular access 1. The guidelines highlight the usefulness of IO access in emergencies when IV access is difficult, and it is faster than central access.
Key Considerations for IO Access
- The tibia and the humerus are preferred sites for IO access, with specific insertion points to avoid complications such as fracture, extravasation, osteomyelitis, infection, compartment syndrome, growth plate injury, and pressure necrosis of the skin 1.
- Success of IO 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 1.
- Devices should be removed as soon as suitable IV access is achieved, ideally within 24 hours of placement, to minimize the risk of complications 1.
Alternative Approaches
- Central venous access, including internal jugular, subclavian, or femoral vein catheterization, is another option but requires more skill and time 1.
- For non-emergent situations, ultrasound-guided peripheral IV placement or techniques to improve peripheral vein visibility, such as heat application, positioning, or having the patient open and close their fist, can be considered 1.
- If medication administration is the primary goal and the situation is not emergent, alternative routes such as intramuscular, subcutaneous, oral, sublingual, or intranasal may be appropriate, depending on the medication and clinical scenario 1.
From the Research
Alternatives to Peripheral Intravenous (IV) Access
If peripheral IV access cannot be obtained, the next step is to consider alternative methods for vascular access.
- Intraosseous (IO) access is a recommended method by the American Heart Association and the European Resuscitation Council to administer resuscitative drugs and fluids when IV access cannot be rapidly or easily obtained 2.
- IO access has few contraindications for use and a low rate of serious complications, making it a viable option in emergency situations 2, 3, 4.
- Studies have shown that IO access is faster and more efficacious compared to central venous catheterization (CVC) in adult patients under resuscitation with impossible peripheral IV access 3, 4.
Comparison of IO Access and Central Venous Catheterization
Research has compared the success rates and procedure times of IO access versus CVC in adult patients under resuscitation.
- IO access has been found to have a higher success rate on first attempt and a lower procedure time compared to CVC 3, 4.
- The mean procedure time for IO cannulation was significantly lower compared to CVC, with a mean time of 2.3 minutes for IO access versus 9.9 minutes for CVC 3.
- IO access is considered a reliable bridging method to gain vascular access for in-hospital adult patients under resuscitation with difficult peripheral veins 3, 4.
Clinical Considerations
It is essential for clinicians to be trained and proficient in placing and using IO devices, as the IO route is recommended by major resuscitation organizations as the preferred route of infusion when rapid, reliable IV access is unavailable 2, 5.
- Newer insertion devices for IO access are easy to use, making the IO route an attractive alternative for venous access during a resuscitation event 5.
- IO access can be achieved quickly with minimal disruption of chest compressions, making it a critical skill for anesthesiologists and other healthcare professionals involved in patient resuscitation 5.