What is the recommended intraosseous (IO) line placement site for a 3-year-old patient requiring immediate vascular access?

Recommended IO Site for a 3-Year-Old

For a 3-year-old child requiring intraosseous access, use the proximal tibia as the primary site, with insertion 1-3 cm below the tibial tuberosity on the flat anteromedial surface. 1, 2

Primary Site: Proximal Tibia

• The proximal tibia is the preferred and most commonly used site for pediatric IO access in children under 5 years of age. 1, 2
• Insert the needle 1-3 cm below the tibial tuberosity on the flat anteromedial surface of the tibia. 2
• At 3 years of age, the medullary diameter is approximately 12 mm, providing adequate space for proper needle positioning. 3
• Use a 25-mm IO needle for this age group, which has demonstrated success rates of 87.5-91.1% in children 13-24 months and older. 4

Alternative Site: Distal Femur

• The distal femur is an acceptable alternative site that may offer marginally higher success rates (89.0% vs 84.7%) compared to the proximal tibia. 5
• Consider the distal femur particularly if the proximal tibia site is inaccessible, traumatized, or if initial tibial placement fails. 5
• The distal femur site is located 1 cm superior to the distal femur physis. 4

Critical Technical Considerations

• Confirm correct needle placement immediately by aspirating bone marrow and administering a test fluid bolus. 3
• Avoid the 25-mm needle in infants under 6 months (failure rate of 100% in one study), but this is not a concern for a 3-year-old. 6
• Insert a luer-lock catheter with a three-way stopcock to minimize needle manipulation after placement. 3
• Use manual pressure or an infusion pump for viscous drugs or rapid fluid boluses, followed by saline flush. 1

Important Safety Warnings

• Remove the IO device as soon as alternative IV access is established, ideally within 24 hours. 7, 3
• Monitor continuously for compartment syndrome, extravasation, and limb perfusion abnormalities. 1, 3
• Serious complications including fractures, compartment syndrome, and amputation have been reported, particularly with prolonged use or malpositioned needles. 1, 6, 3
• Avoid infusing inotropic medications through IO access after the initial resuscitation phase. 3

Medications and Fluids

• All intravenous medications can be administered intraosseously, including epinephrine, adenosine, fluids, blood products, and catecholamines. 1
• Drug onset and levels are comparable to IV administration. 1
• Follow each medication with a saline flush to promote entry into central circulation. 1