From the Guidelines
Intraosseous (IO) cannulation is a recommended emergency procedure for establishing vascular access when peripheral or central venous access cannot be quickly obtained, with the most recent guidelines suggesting its use in both adults and children 1.
Key Considerations for IO Cannulation
- The preferred sites for IO placement are the proximal tibia, distal tibia, and the humeral head, with careful consideration to avoid the epiphyseal growth plate in children 1.
- For adults, a 15G or larger needle is recommended, while for children, a 16-18G needle is suggested 1.
- Common devices used for IO cannulation include the EZ-IO, FAST1, and BIG systems, with the choice of device depending on the specific clinical scenario and patient factors 1.
Placement and Confirmation
- Placement is confirmed by aspirating bone marrow, observing fluid flow without extravasation, feeling the support of the needle by the bone cortex, and successful infusion under gravity alone 1.
- After confirming placement, the needle should be secured, and infusion begun, with any medication or fluid that can be given intravenously administered via IO using the same dosages 1.
Complications and Replacement
- Common complications of IO cannulation include compartment syndrome, osteomyelitis, and extravasation, emphasizing the need for careful technique and monitoring 1.
- IO access should be replaced with conventional vascular access as soon as possible, ideally within 24 hours, to minimize the risk of complications 1.
Effectiveness and Safety
- IO cannulation is effective because the bone marrow cavity contains a non-collapsible venous network that drains directly into the central circulation, making it an excellent alternative when traditional vascular access fails during emergencies 1.
- The safety and efficacy of IO drug delivery have been supported by prospective trials in both children and adults, although more research is needed to fully understand its effectiveness in cardiac arrest scenarios 1.
From the Research
Intraosseous (IO) Cannulation
- Intraosseous (IO) access is a safe and effective alternative to conventional intravenous access (IA) in emergency situations when IA cannot be obtained 2.
- IO access is attainable in all age groups and can be used for fluid resuscitation, drug delivery, and blood collection 2.
- The use of a semi-automatic IO infusion system (EZ-IO) has been shown to be a quick, easy, and reliable alternative to conventional venous access in critically ill patients 2.
Comparison of IO and Central Venous Catheterization
- IO vascular access has been compared to central venous catheterization (CVC) in adults with difficult peripheral veins, with IO access showing higher success rates on first attempt and lower procedure times 3.
- The success rate of IO cannulation was 85% compared to 60% for CVC, and the procedure time was significantly lower for IO access (2.0 minutes vs 8.0 minutes) 3.
Ultrasound-Guided Peripheral Venous Cannulation
- Ultrasound guidance has been shown to increase the likelihood of successful cannulation in patients with difficult venous access 4, 5.
- However, one study found that ultrasonographically guided peripheral intravenous cannulation did not decrease the number of attempts or the time to successful catheterization, nor did it improve patient satisfaction compared to the group that did not use ultrasonography 6.
Advantages and Disadvantages of IO Cannulation
- The main advantage of using IO cannulation is to obtain secure, immediate, non-collapsible peripheral venous access in critically ill patients 2.
- IO cannulation can be performed quickly and easily, with all insertions achieved within 30 seconds and successful upon the first attempt in one study 2.
- However, IO cannulation may not be suitable for all patients, and the use of ultrasound-guided peripheral venous cannulation may be preferred in some cases 4, 5.