Journal of Clinical Anesthesia (2013) 25, 447451

Original Contribution

Anesthesia through an intraosseous line using an 18-gauge

intravenous needle for emergency pediatric surgery,
Riyadh Khudeir Hamed MD (Senior Specialist Anesthesiologist & Specialist Pediatric
and Neonatal Anesthesiologist) a ,
Sharon Hartmans MD (Resident in Internal Medicine)b ,
Marianne Gausche-Hill MD, FACEP, FAAP (Professor of Clinical Medicine;
Vice Chair, Department of Emergency Medicine)c,d,
a

Department of Pediatric and Neonatal Anesthesia, Childrens Welfare Teaching Hospital, Medical City, Baghdad, Iraq
Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA 90509, USA
c
Department of Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA 90095, USA
d
Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA; Los Angeles Biomedical Research
Institute at Harbor-UCLA, Torrance, CA 90509, USA
b

Received 29 July 2012; revised 15 February 2013; accepted 1 March 2013

Keywords:
Anesthesia: intraosseous
route;
Catheterization;
Emergency surgery;
Pediatrics

Abstract
Study Objective: To describe the success and complication rate of intraosseous (IO) access for delivery
of anesthesia with the use of an 18-gauge (G) intravenous (IV) needle.
Design: Prospective study.
Setting: Childrens Welfare Teaching Hospital, Baghdad, Iraq.
Patients: 300 critically ill infants and toddlers, age 3 weeks to 16 months, requiring emergency surgery
for intra-abdominal or pelvic conditions, in whom peripheral or central access was not obtainable.
Patients presented for surgery between 2007 and 2010.
Interventions: In 26 patients, the IO catheter was established when peripheral access was not obtained
at the outset of surgery; in 4 patients standard peripheral vascular access failed during the surgical
procedure and IO access was obtained. An 18-G IV needle was placed into the proximal tibia and
attached to an extension set with a 3-way stopcock to deliver anesthesia.
Main Results: For 26 critically ill children and 4 other children, IV access failed during delivery of
anesthesia; vascular access was successfully obtained within minutes in all 30 infants (100%) using the
intraosseous route. Ninety percent (27/30) of patients awoke immediately postoperatively in good
condition; 10% (3/30) went to the pediatric intensive care unit (PICU) for further care due to their
critical preoperative condition. Complications associated with use of the IO route were considered minor
(3/30 pts [10%]) and included extravasation of fluid in two cases and cellulitis in one.

Supported by departmental funding only.

The authors have no conflicts of interest to disclose.
Correspondence: Marianne Gausche-Hill, MD, FACEP, FAAP, Department of Emergency Medicine, Harbor-UCLA Medical Center, 1000 W. Carson St.,
Box 21, Torrance, CA 90509, USA. Tel.: +1 310 222 3503, 222 6740; fax: + 1 310 212 6101.
E-mail addresses: drriyadhkh@yahoo.com (R.K. Hamed), mgausche@emedharbor.edu (M. Gausche-Hill).

0952-8180/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jclinane.2013.03.013

448

R.K. Hamed et al.

Conclusion: The IO route provided for rapid delivery of anesthesia, induction, and maintenance in this
series of critically ill infants undergoing emergency surgery when other vascular access routes failed.
Few complications were noted. Intraosseous access was achieved through a simple technique using an
18-gauge IV needle.
2013 Elsevier Inc. All rights reserved.

1. Introduction
Securing a line for anesthesia in a hypovolemic patient
prior to surgery may be very difficult sometimes
impossible. When this happens, an intraosseous line (IO)
is a safe, quick, and effective alternative [1]. The IO line is
established in less than two minutes and is a significantly
more rapid site for venous access than central venous
access [2].
Although the IO line is often considered as an alternative
vascular access site in pediatric patients, it may be used in a
patient of any age [3,4]. The IO route provides access to the
systemic venous circulation via the marrow or medullary
cavity with its surrounding bone, and provides a noncollapsible entry point into the central venous circulation.
Previous studies have demonstrated that the IO route is just
as efficacious for medication administration as the intravenous (IV) route, with nearly identical pharmokinetics [5,6].
The use of spinal needles and standard injection needles for
IO access has been discouraged because of the flexibility of
the needle wall (spinal) or possible obstruction of the
injection needle without a stylet by a bone plug [7,8]. The
creation of specialized IO needles and new IO access
devices, including devices that drill the IO needle into the
bone (EZ-IO drill; Vidacare, San Antonio, TX, USA) and
the spring-loaded, impact-driven devices such as the
Bone Injection Gun (B.I.G.; WaisMed, Kansas City,
MO, USA), have made placement of the IO line easy in
the emergency setting [2,8,9]. While there are numerous
reports of IO line placement in various conditions in the
prehospital and emergency department settings, there are
considerably fewer reports of their use in the perioperative
setting [8].
We describe an approach to IO access in pediatric patients
who failed peripheral and central venous access attempts
during anesthesia administration for emergency surgery in a
large teaching hospital in Baghdad, Iraq.

2. Materials and methods

This case series was submitted to the Institutional Review
Board (IRB) at Harbor-UCLA Medical Center for review; it
was determined that this historical cohort did not fall under
the category of research, as defined in 45CFR46.102(d), and
is exempt. From 2007 to 2010, approximately 4,000
pediatric patients presented to the Childrens Welfare

Teaching Hospital in Baghdad, Iraq, for emergency surgery.

The hospital is a tertiary-care referral center with 200
pediatric ward beds and 8 pediatric intensive care unit
(PICU) beds. Most patients are transferred to this hospital
from neighboring villages and government health centers for
a higher level of care. However, due to ongoing military
action in Iraq, patient transportation is often delayed for
security issues and patients present in a hypovolemic state,
without peripheral venous access.
We describe a series of 30 pediatric patients who
received anesthesia via an IO line after several attempts to
gain peripheral or central IV access failed or a working
peripheral IV catheter failed during surgery. Since automated IO drills were not available in Baghdad at the time
of this study, we used a standard 18-gauge (G) IV needle
with a handmade IV extension set. The gauge of the needle
was chosen to insure successful insertion without deformation of the needle. A standard plastic cap from an IV
cannula set was used to stabilize the physicians thumb on
the end of the 18-G needle for insertion. The needle was
inserted only until a pop was felt and marrow was
withdrawn or fluids infused.

3. Results
Over a 3-year period (2008-2010), we placed IO lines in a
total of 30 pediatric patients. In 26 patients, we placed an IO
line when peripheral or central IV access was not achieved
prior to induction of anesthesia. In the remaining 4 patients,
we placed IO lines after the start of anesthesia for a failed IV
during surgery. In all patients, IO access was a quick, easy
and reliable way to obtain access for anesthesia for these lifesaving operations.
The most common reason for emergency surgery in
our patient population was intestinal obstruction
(Table 1). Intraosseous placement occurred in 5 patients
with intussusception, 4 with congenital pyloric stenosis
and severe dehydration, 3 with abdominal or hepatic
tumors, 3 cases of congenital diaphragmatic hernia, and
a one month patient with vaginal bleeding due to a
rectovaginal fistula.
The most common site for IO access in children is the
proximal tibia. The location was estimated by measuring one
fingerbreadth below and medial to the tibial tuberosity along
the proximal tibia [8,10]. The distal femur, and distal tibia are
alterative sites for IO infusion in children, which we did not

IO line in emergent pediatric surgery in Iraq

449

Table 1 Type of emergency surgery performed on 26 patients

in whom anesthesia was initiated by intraosseous (IO) line
Type of surgical operation

Cases Patients
(n)
age range

Exploratory laparatomy for intestinal

obstruction
Partial resection of colon & colostomy
for intestinal obstruction
Reduction/resection of intussusception
Pyloroplasty for pyloric stenosis
Abdominal & hepatic tumor resection
Congenital diaphragmatic hernia repair
Rectovaginal fistula repair

3 - 7 mos

3 wks - 9 mos

5
4
3
3
1

4 wks - 4 mos
4 - 7 wks
6 - 8 mos
3 - 6 wks
16 mos

An additional 4 patients had an IO line placed after a peripheral

line failed during surgery.

Fig. 2 Critically ill 7 month old infant with intestinal obstruction,

with intraosseous line placed for induction of anesthesia.

use. In all situations, the IO needle was placed successfully

within a minute.
At the time of our study, our hospital lacked IO needles
or an automatic IO drill. An alternative technique was
created using an ordinary 18-G IV needle. We attached the
plastic cap cover from a disposable IV cannula set to the
syringe needle so that we could easily handle it during
penetration through the bone cortex. After sterilization of
the site, we advanced the needle through the bone cortex
with a twisting motion at a 90 angle until reaching the
marrow (Fig. 1). After confirmation of proper positioning of
the needle by aspiration of marrow, we secured the needle
with adhesive tape and gauze pads (Fig. 2). Then we
connected the needle to a handmade extension set with a 3way stopcock for anesthesia infusion. In most cases, IO
access was obtained in the awake state due to patients
critical condition and the risk of sedating a neonate prior to

securing vascular access. In the few cases where the

patients condition permitted, we used halothane to induce
mild anesthesia prior to attempting to place an IO line.
Perioperative antibiotics were used in all cases.
The induction and maintenance of anesthesia in these
surgical operations was without serious complications. For
induction therapy, we infused ketamine (1 - 2 mg/kg),
followed by succinylcholine (1-2 mg/kg) and pancuronium
or atracurium. For maintenance therapy, we used halothane, and for reversal we used neostigmine (0.04 mg/kg)
with atropine (0.02 mg/kg). We also administered blood
products, fluids, and hydrocortisone as needed through the
IO line. After the procedure, we replaced IOs with IV lines
as soon as possible, typically within a few hours of
surgery. In all patients, IV or central lines were established
within 6 hours of the completion of surgery. Ninety
percent (27/30) of our patients awoke immediately
postoperatively in very good condition and were referred
to the pediatric surgical ward. The other 10% (3/30) went
to the PICU and neonatal ICU for further care due to their
critical preoperative condition.
There were few complications in this series of patients. In
two cases, we noted extravasation of fluid during surgery.
When this occurred, we used the tibial bone of the opposite
leg and proceeded without further complications. One patient
developed cellulitis postoperatively.

4. Discussion

Fig. 1 Critically ill newborn with intestinal obstruction, shown

with a proximal tibial intraosseous line placed for induction
of anesthesia.

The idea that an IO line might be used to deliver

anesthetic agents was first proposed in 1952 [11]. Tarrow
et al suggested that in addition to fluids such as normal
saline, whole blood, and antibiotics, the IO route might be of
interest to anesthesiologists due to the extensive blood

450
supply in the marrow. However, since their study, only a
limited number of studies have reported the use of IOs for
general anesthesia in pediatric patients [12-16].
The largest study to date was reported by Neuhaus
et al and describes the semi-elective use of anesthetic
infusion via an IO line [12]. A total of 14 children had
IOs placed when peripheral IV cannulation failed. In this
multi-center trial, authors inserted IOs into the proximal
tibia of patients with either an automated drill or manual
IO needle. They infused hypnotics, neuromuscular blocking agents, opioids, cardiovascular drugs, antibiotics, and
IV fluids without any significant complications.
Similarly, two case reports describe the use of IOs in
infants with cyanotic heart disease when peripheral IV access
was unattainable. Steward and Kain report on the case of a
3 month old infant who required ventriculoperitoneal shunt
revision [13]. The first attempt to place the shunt was
canceled after several experienced anesthesiologists were
unable to establish venous access. Two weeks later, when a
revision was attempted, they placed an IO after attempting
peripheral IV placement for 20 minutes. Once the IO was
secured, they were able to successfully administer pancuronium, lactated Ringers solution, and antibiotics without
any complications.
Joseph and Tobias described the case of an 8 month old
infant with cyanotic congenital heart disease undergoing
direct laryngoscopy and bronchoscopy to evaluate for
tracheomalacia and vascular compression of the airway
[14]. Three experienced pediatric anesthesiologists attempted
to secure a peripheral line. After 15 to 20 minutes of
unsuccessful attempts, they placed an IO and infused
propofol for anesthesia, without any complications in the
postoperative period.
Alternatively, several reports have been published on
the use of IOs to induce anesthesia for emergency airway
management in children. Katan et al described using an
IO line to infuse lidocaine, thiopental sodium, and
succinylcholine chloride for rapid-sequence intubation in
a 6 month old child with elevated intracranial pressure
and seizures secondary to suspected abusive head trauma
[15]. Tobias and Nichols described two cases of IO
anesthesia for rapid-sequence intubation [16-18]. They
administered atropine, lidocaine, succinylcholine, and
thiopental via the IO route. In both cases, they noted
muscle relaxation in 45 seconds and were able successfully to perform intubation.
Prior studies have demonstrated the effectiveness of IOs
in children for use in elective surgery, emergency airway
management, and in infants with cyanotic heart disease.
However, this study demonstrated the effectiveness of IOs
for induction of general anesthesia in emergency surgery and
adaptation of the 18-G IV needle for use in resource-poor
developing countries.
In our patient population, we experienced few complications, consistent with the published literature [1,8].
Extravasation of fluid is a known complication and

R.K. Hamed et al.

potentially leads to tissue damage from medication or
compartment syndrome. In the two cases in which we noted
extravasation of fluid, we quickly remedied the situation by
changing placement of the IO line to the alternate tibia.
Osteomyelitis is another serious complication in IO
cannulation; however, it occurs infrequently and we did
not encounter any cases within this study. In a metaanalysis,
Rosetti et al observed that ostemyelitis occurred in only
0.6% of more than 4,000 cases and that the overall failure
rate of IO infusions was only 2.1% [1]. Finally, we did not
encounter any complications with the use of an 18-G
needle, such as obstruction by a bone plug. The flexibility
of the needle wall was not problematic either, as we used a
needle with a large enough gauge to prevent bending, and
we stabilized it with the plastic cap cover from a disposable
IV cannula set.
If specialized IO needles or IO automatic drills are not
available, IO access may be reliably achieved through a
simple technique using an 18-G needle. Although it is not the
first-line method for anesthesia induction, the IO route
should be considered by pediatric anesthesiologists in cases
where peripheral and central venous access have failed after
several unsuccessful attempts.

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