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Intraosseous infusion

Author: Catherine E Perron, MD

Section Editors: Anne M Stack, MD, Allan B Wolfson, MD
Deputy Editor: James F Wiley, II, MD, MPH

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2017. | This topic last updated: Aug 17, 2017.

INTRODUCTION — This topic will discuss intraosseous (IO) infusion in children and adults, including
indications, contraindications, and techniques according to device.

Other forms of venous access are discussed separately:

● (See "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies" and
"Peripheral venous access in adults".)

● (See "Peripheral venous access in adults".)

● (See "Overview of central venous access".)

● (See "Principles of ultrasound-guided venous access".)

BACKGROUND — Establishment of access to the circulation is a critical component of resuscitation.

The preferred venous access site during cardiopulmonary resuscitation (CPR) is the largest, most
accessible vein that does not require the interruption of resuscitation. Peripheral venous access is
attempted before attempting other forms of vascular access if peripheral veins can be readily seen or
palpated. (See "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies"
and "Peripheral venous access in adults".)

Intraosseous (IO) infusion, a technique for vascular access, was described first in 1922 and was
widely used for drug administration in children in the 1940s [1-6]. It fell out of favor during the 1950s
and 1960s, when disposable intravenous catheters were developed and techniques for insertion
improved. In the 1980s, after the publication of numerous clinical reports of its effective use in children
and animal models [7-10], the practice of IO infusion increased. Use in adults has also grown,
especially in the prehospital setting [11,12]. Today, the procedure is reserved for acute, life-threatening
or medically necessary situations when standard venous access methods cannot be rapidly achieved
and as the first attempt at vascular access in cardiopulmonary arrest or severe shock in selected
patients.

ANATOMY — Intraosseous (IO) infusion is possible because of the presence of veins that drain the
medullary sinuses in the bone marrow of long bones (figure 1) [13]. These veins, supported by the
bony matrix, do not collapse in patients with shock or hypovolemia. The following list provides the site
and draining vessels for the most commonly used sites:

● Proximal tibia – Popliteal vein

● Femur – Branches of the femoral vein

● Distal tibia (medial malleolus) – Great saphenous vein

● Proximal humerus – Axillary vein

● Manubrium (upper sternum) – Internal mammary and azygos veins

The anterior inferior iliac spine, clavicle, and distal radius have also been used successfully for IO
vascular access as have bones without medullary cavities, including the calcaneous and radial styloid
[14-16].

TRAINING — Intraosseous (IO) cannulation is likely to be used by the emergency care provider
during resuscitation. The patient’s life may well depend upon the clinician’s ability to secure vascular
access. Thus, emergency physicians and others who may need to perform IO cannulation emergently
should learn to do so well in advance of the immediate need.

Training can take place on simulation models, animal bones (eg, chicken or turkey legs), or a cadaver.
IO placement is taught as part of the Pediatric Advanced Life Support, Advanced Pediatric Advanced
Life Support, and Advanced Trauma Life Support Courses. After training, typically consisting of a one-
hour lecture followed by a one-hour hands-on experience, novice users have achieved success rates
of 93 to 97 percent for manual and battery-powered IO placement in a variety of simulated settings
[17-21].

High success rates with battery-powered IO placement have also been shown in field and hospital
care after such training:

● Paramedics achieved an 87 percent success rate for field IO placement in infants under two
years of age [22].

● Military medics achieved a 97 percent success rate for IO cannulation in children and adults
during combat situations [22].

● Physicians achieved a 94 percent success rate for IO placement in 95 children treated in an

emergency department [23].

INDICATIONS — We recommend that infants and children in cardiopulmonary arrest or severe shock
who do not have readily available intravenous access undergo intraosseous (IO) cannulation rather
than central venous line placement or surgical venous cutdown.

We suggest that adults in cardiopulmonary arrest or severe shock who do not have readily available
intravenous access also undergo IO cannulation rather than central venous line placement or surgical
venous cutdown.
IO cannulation may also be appropriate in emergent or urgent situations where reliable venous access
cannot be achieved quickly (eg, patients with shock, sepsis, status epilepticus, extensive burns,
multiple trauma) or in patients for whom intravascular access is medically necessary and cannot be
achieved by other means despite multiple attempts [24]. In awake patients, analgesia is warranted
prior to infusion if the patient’s condition permits. (See 'Analgesia' below.)

IO cannulation permits intravascular access through which diagnostic studies may be obtained, fluid
resuscitation may occur, and a wide variety of medications can be rapidly delivered. (See 'Diagnostic
studies' below and 'Fluid and drug administration' below.)

The American Heart Association and the International Committee on Resuscitation endorse the use of
IO access as a safe and effective means of vascular access in critically ill children and adults [25,26].
IO cannulation permits rapid intravascular access in critically ill children and adults as demonstrated
by the following reports:

● Children

• In a trial comparing success rates and time to insertion between IO and peripheral IV access
among children requiring fluid resuscitation for severe dehydration in a hospital setting, the
IO route was successful within five minutes for 100 percent of patients, as compared with 67
percent success within five minutes for peripheral IV placement [27].

• In a retrospective series describing attempts by paramedics to establish peripheral IV access

for 300 children (0 to 18 years) in the prehospital setting, IV access was successful in two-
thirds of all children and in only 49 percent of a subset of children younger than six years of
age [28].

• In an observational series describing the use of IO cannulation in patients of all ages in the
prehospital setting, the overall success rate was 76 percent, with 85 percent success in
children between one and two years of age [29].

• IO vascular access was achieved in less than one minute for 85 percent of cases in a
prospective report evaluating the time to insertion and success rate of IO cannulation in a
variety of prehospital settings [30].

● Adults

• In a trial of 182 adults receiving vascular access for cardiac arrest in the prehospital setting,
tibial IO placement was associated with a significantly higher frequency of initial vascular
access success than peripheral IV placement (91 versus 43 percent, respectively) [31].
Although initial success with humeral IO access was higher than for peripheral IV access (71
versus 49 percent), overall success was not significantly different because of a high rate of
IO catheter displacement among patients with humeral IO cannulas. (See 'Sites of
placement' below.)

• A trial of IO needle placement using a battery-powered driver or spring-loaded device in 40

adults receiving prehospital care found that vascular access was successfully achieved on
the first attempt in 80 to 90 percent of patients, and within two minutes [32].
 • A prospective observational study compared IO cannulation using a battery-operated driver
device (EZIO) with internal jugular or subclavian central venous access in 10 adult patients,
all of whom received both procedures [33]. IO access was achieved on the first attempt more
frequently (90 versus 60 percent) and took significantly less time (2 versus 10 minutes) than
central venous access.

Taken together, these studies suggest that establishing peripheral IV access often is delayed or
unsuccessful during resuscitation of critically ill patients, particularly small children. Furthermore,
alternative methods of vascular access such as central venous access by percutaneous or surgical
venous cutdown takes much longer and are less likely to be successful than IO placement. Finally, all
drugs and fluids that might be delivered through peripheral or central venous lines can also be
administered through an IO cannula. (See "Vascular (venous) access for pediatric resuscitation and
other pediatric emergencies", section on 'Central access' and "Vascular (venous) access for pediatric
resuscitation and other pediatric emergencies", section on 'Venous cutdown' and 'Fluid and drug
administration' below.)

In adults, difficult or failed peripheral vascular access is also problematic, especially in the prehospital
setting. Alternative approaches to IO cannulation such as ultrasound-guided peripheral IV access and
central venous access also achieve high success rates but take longer to perform than IO access.
(See "Principles of ultrasound-guided venous access" and "Principles of ultrasound-guided venous
access", section on 'Dynamic ultrasound to guide vein cannulation' and "Principles of ultrasound-
guided venous access", section on 'Peripheral intravenous access'.)

IO cannulation by manual insertion becomes progressively more difficult as children age because the
cortex of bone becomes thicker and the tibial bone marrow cavity becomes smaller [6,34]. The
development of devices such as impact-driven devices and battery-operated handheld drivers has
made IO cannulation feasible for patients of all ages [23,25,35]. (See 'Techniques' below.)

Fluid and drug administration — Any intravenous drug or routine resuscitation fluid can be
administered safely by the IO route. Examples include epinephrine, dopamine, dobutamine,
adenosine, digitalis, heparin, lidocaine, atropine, sodium bicarbonate, phenytoin, neuromuscular
blocking agents, antibiotics, crystalloids, colloids, and blood products [8,10,34,36-41]. Drug and fluid
dosing is the same as for intravenous administration [24,38]. However, for adenosine, the IO route
may not be as effective as upper extremity peripheral intravenous access for the treatment of
supraventricular tachycardia in some young infants [42].

When medications are given, the IO cannula should be flushed before and after each medication that
is administered. Only compatible drugs may be administered simultaneously through an IO needle or
catheter. The IO site and extremity should be monitored frequently for infiltration.

The onsets of action and serum drug concentrations after IO infusion during cardiopulmonary
resuscitation (CPR) are comparable to those achieved after intravenous administration [9,43]. Studies
in animals suggest that the IO route is as effective as the central intravenous route [9,44,45] and may
be superior to the peripheral intravenous route during cardiac arrest [9].

Rapid fluid administration and viscous drugs — Crystalloid fluids (eg, normal saline) for rapid
volume expansion and viscous drugs and solutions should be administered under pressure using an
infusion pump, pressure bag, or manual injection through a syringe and stopcock. These approaches
overcome the resistance of emissary veins that lead from the intramedullary cavity to the general
circulation [46]. The IO site and extremity should be monitored frequently for infiltration during rapid
fluid administration.

Infusion rates equivalent to a 21 gauge peripheral intravenous catheter are typically achieved [47]. As
an example, in a prospective observational study in 24 adults receiving emergency treatment and in
whom peripheral venous access could not be achieved, mean rates of fluid administration under
pressure were 165 mL/min at the tibial site and 153 mL/min at the humeral site [48]. Among patients
who had placement of an IO at both sites, the rate of fluid administration was not significantly different.
In another study performed in 16 fresh cadavers, mean flow rates achieved during IO infusion rates
under high pressure (300 mmHg) was highest at the sternal site [49]. However, this rate (94 mL/min)
was lower than what has been described in adult patients receiving fluid therapy [48] and suggests
that the cadaveric model may not be directly applicable to the clinical setting.

Diagnostic studies — Based upon comparisons of venous blood and bone marrow samples in
children with cancer, bone marrow samples initially obtained from an IO line during placement may be
used for a variety of diagnostic studies including glucose, hemoglobin, pH, pCO2, serum bicarbonate,
sodium, chloride blood urea nitrogen, creatinine, serum drug levels, and cultures (eg, bacterial, viral,
or fungal cultures) [50,51]. By contrast, bone marrow values for blood oxygenation, white blood cell
count, potassium, aspartate aminotransferase, alanine aminotransferase or ionized calcium may not
be accurate.

In a study of 28 adult patients, bone marrow aspirates accurately identified blood ABO and Rh type
[52]. Thus, bone marrow samples may also be used for type and screen if a standard blood sample is
not available.

A canine model suggests that IO drug administration may alter subsequent laboratory measurements
[53]. Thus, most experts do not advise using IO access for diagnostic studies once drugs have been
administered.

CONTRAINDICATIONS — There are relatively few absolute contraindications to intraosseous (IO)

infusions because the technique is primarily indicated in life-threatening emergencies:

● A fractured bone or previously penetrated bone cannot be used because fluids will exit through
the fracture or puncture site.

● An extremity with vascular interruption, either from trauma or cutdown attempt, is not suitable for
IO infusion because the fluid or drugs administered into the bone marrow will leak through the
open blood vessel.

If possible, IO cannulation should be avoided in the following patients:

● Patients with cellulitis, burns, or osteomyelitis involving the cannulation site [44,46].

● Patients with osteogenesis imperfecta or osteopetrosis, who have increased bone fragility.
However, successful IO cannulation in a child with osteogenesis imperfecta has been described
[44].
 ● Patients with right-to-left intracardiac shunts (eg, tetralogy of Fallot, pulmonary atresia), who may
be at greater risk for cerebral fat or bone-marrow emboli [44,54,55]. (See 'Complications' below.)

PREPARATION — In most instances, intraosseous (IO) cannulation occurs as part of care for a life-
threatening emergency. Thus, informed consent is typically implied. In awake patients for whom IO
needle placement is necessary, the patient and, in children, the caretaker should receive a detailed
explanation of the procedure and provide informed consent. Awake patients should receive local
anesthesia prior to IO cannulation attempts. (See "Subcutaneous infiltration of local anesthetics".)

Equipment — The following equipment should be assembled prior to the procedure:

● Chlorhexidine, povidone iodine solution or similar antiseptic

● Surgical mask and eye covering for the clinician performing the procedure

● Sterile latex-free gloves

● 10 mL syringe

● Syringe with saline flush

● IO needle and/or device

● In awake patients, small-volume syringe (eg, 3 mL) containing lidocaine 1 percent for infiltration
via a small bore needle (eg, 25 gauge needle)

Intraosseous (IO) needles and devices — Commercially available intraosseous cannulation are
preferred for IO cannulation as follows [14,24]:

● Manual IO needles – Examples include the Jamshidi (Cardinal Health, McGraw Park, IL) and the
modified Dieckmann (Cook Critical Care, Bloomington, IN). Important features include a trocar, a
short needle length with a handle that provides a resting place for the palm, and an adjustable
flange or depth marking to guide placement. (See 'Manual insertion technique' below.)

● Battery-powered driver (EZIO) – The EZIO comes with a lithium powered battery driver and
needle sets in three lengths for placement in children and adults. (See 'Battery-powered driver'
below.)

● Impact-driven devices (Bone injection gun [BIG], FAST1) – The bone injection gun comes in
two sizes that allow IO placement in children and adults. The FAST1 is designed for sternal IO
catheter placement in patients ≥12 years of age. (See 'Impact-driven devices' below.)

Other types of needles may be used if an IO needle or device is not available; these include bone
marrow needles, styletted needles, and spinal needles [44,56]. Of these, bone marrow needles are
best because they are least likely to bend. Standard hypodermic needles should not be used for IO
infusion because they often become clogged with bone and bone marrow.

Sites of placement — We recommend that all patients who undergo IO placement for life-threatening
illness (eg, cardiac arrest) have the first attempt occur at the proximal tibial site, unless otherwise
contraindicated. Preferred alternative sites vary based upon the age and skeletal maturity of the
patient (table 1). A battery-powered or impact driven device is typically required to accomplish IO
placement in the proximal tibia of patients six years of age or older. If such a device is not available,
then the clinician should attempt manual placement at the medial or lateral malleolus in older patients.
(See 'Indications' above and 'Contraindications' above.)

In a trial of 183 adults undergoing prehospital vascular access for cardiac arrest, tibial IO placement
was significantly more likely to result in successful vascular access when compared to humeral IO or
peripheral intravenous (IV) access (91 versus 53 and 41 percent, respectively) [31]. Loss of vascular
access during transport was more likely with humeral IO access than either tibial IO or peripheral IV
placement. The time to achieve vascular access ranged from five to seven minutes and was similar
among the three techniques.

The primary anatomic locations for IO cannulation are as follows (table 1) [38,44]:

● Proximal tibia – In children, the proximal tibial site is approximately 2 cm below the tibial
tuberosity and up to 1 cm medially on the tibial plateau (figure 2). In skeletally mature adolescents
and adults, the recommended site is 2 cm medial to and 1 cm above the tibial tuberosity. The
proximal tibial site is rapidly identified and most familiar to emergency clinicians. Furthermore, in
patients with cardiac arrest, proximal tibial IO placement avoids interfering with ongoing cardiac
compressions. (See 'Manual insertion technique' below and 'Bone injection gun' below.)

● Distal femur – The distal femur site is in the midline approximately 1 to 2 cm above the superior
border of the patella with the leg in extension. This site is an alternative site for manual or device-
assisted IO placement in infants and young children in whom the IO needle can traverse the
tissues of the distal thigh and still reach the marrow cavity (figure 3). (See 'Manual insertion
technique' below.)

● Distal tibia or fibula – The malleoli sites are approximately 1 to 2 cm superior to the malleoli in
the bone’s axis. The medial malleolus (distal tibia) is preferred to the lateral malleolus (figure 4).
These sites are available for manual or device-assisted IO placement in children, adolescents,
and adults. (See 'Techniques' below.)

● Proximal humerus – The greater tubercle of the proximal humerus is appropriate for IO
placement in skeletally mature adolescents and adults. To identify this site, the clinician should
adduct and internally rotate the upper arm (hand on abdomen) to make damage to the medial
structures of the axillary plexus unlikely. The greater tubercle of the proximal humerus is located
approximately 2 cm below the acromion process. Alternatively, it can be directly palpated from
below. (figure 5). This site typically requires a battery-powered driver or spring-loaded impact
device for successful IO cannulation. (See 'Battery-powered driver' below and 'Bone injection gun'
below.)

● Manubrium – The superior one-third of the sternum may be accessed in adults using a specially
designed IO device (FAST1 IO infusion system, PYNG medical, Richmond, British Columbia,
Canada) [57]. The device comes with a target patch that is applied along the sternal notch to
assist with site identification and placement. (See 'FAST1' below.)

Choice of device — The choice of device (manual, battery-powered, or impact-driven) varies by age
as follows:
 ● Younger than one year of age – We suggest that, in infants under one year of age, clinicians
use manual needles or battery-powered devices for IO insertion rather than an impact-driven
device. Observational studies suggest that the success rates for manual placement and battery-
powered devices in infants are similar, and both techniques have been shown to be easily
learned by a variety of health care providers [18,20,22,23]. Manual IO needles are less expensive
and are more widely available than other devices. Time to manual IO placement is longer than for
a battery-powered device but shorter than for an impact-driven device.

● One year of age and older – We suggest that, in children one year of age or older, adolescents,
and adults, clinicians use a battery-powered device for IO placement, if available, rather than a
manual needle or impact-driven device. Success rates for patients in these age categories
appear to be higher with battery-powered IO placement and time to insertion is shorter.

Available evidence indicates the following success rates and time to IO insertion in children and
adults undergoing resuscitation:

• Manual needles: 76 to 100 percent (50 to 67 percent in patients over one year of age)
[29,58-60], median time to insertion 38 seconds [59]

• Battery-powered driver: 87 to 97 percent [22,23,61], median time to insertion <10 seconds

[23]

• Bone injection gun: 45 to 91 percent [59,62-64], median time to insertion 49 seconds [59]

● FAST1: 72 to 95 percent [59,61,65], median time to insertion 62 seconds [59]

Evidence to guide the choice of IO insertion device is limited to observational studies and small trials
that vary according to the setting (eg, prehospital, hospital), clinical provider (eg, paramedic, medic,
physician), site of insertion, and patient population (pediatric or adult) and do not allow direct
comparisons among all devices available. In order to maximize the chance of successful IO
cannulation, proper training is essential prior to use, regardless of which IO insertion technique is
chosen. (See 'Training' above.)

Suggested sites of IO placement are discussed separately. (See 'Sites of placement' above.)

Analgesia — In critically ill children and adults who require immediate vascular access (eg, patients in
arrest or severe shock), IO placement is performed without analgesia [66]. These patients may
receive systemic analgesia (eg, fentanyl intraosseously) or infusion of preservative-free lidocaine, as
described below, if they become responsive to pain once the IO is placed and as tolerated by their
clinical condition.

In awake patients for whom IO placement is in response to difficulty with peripheral venous access
and whose condition is not emergent, we suggest analgesia for IO placement be provided by local
infiltration of anesthetic at the IO site and administration of preservative-free lidocaine through the IO
cannula prior to infusion of medications, fluids, or blood products. Infiltration of the periosteum is
necessary to achieve analgesia prior to placement (see "Subcutaneous infiltration of local
anesthetics", section on 'Direct infiltration'). In one observational study of 1119 patients from the
manufacturer database, the pain of EZ-IO insertion in children and adults was less than the pain
during infusion (mean pain score 3.4 versus 5.4, respectively) [67]. Thus, local infiltration of the IO
insertion site with local anesthetic may not be necessary in adolescents and adults when using a
battery-powered driver.

If electing to provide analgesia prior to IO infusion, use preservative-free intravenous lidocaine as

follows [66]:

● The usual initial dose is 0.5 mg/kg lidocaine (0.025 mL/kg of 2 percent [20 mg/mL] preservative-
free lidocaine formulation for intravenous use, maximum dose: 40 mg [2 mL]). Observe
recommended cautions and contraindications for administration of intravenous lidocaine. (See
"Major side effects of class I antiarrhythmic drugs", section on 'Lidocaine (intravenous)'.)

● For pediatric and adult patients weighing 40 kg or greater, prime the connection tubing with
lidocaine. For the EZ-Connect system, the priming volume is approximately 1.0 mL which
corresponds to 20 mg of preservative-free lidocaine 2 percent. After IO placement, attach the
tubing to the IO and administer intravenous lidocaine by attaching a syringe containing an
additional 20 mg of preservative-free intravenous lidocaine 2 percent. Slowly infuse the lidocaine
over two minutes.

● For pediatric patients weighing less than 40 kg, administer intravenous lidocaine after IO
placement by carefully attaching the syringe directly to the needle hub. Aspirate the IO needle to
remove air and then slowly infuse the intravenous lidocaine by syringe over two minutes. Then
connect tubing primed with normal saline to the IO.

● Allow lidocaine to dwell in the IO space for one minute after slow infusion.

● Flush the IO with 5 to 10 mL of normal saline. Some clinicians prefer to flush once with
heparinized saline (10 units/mL in infants <10 kg and 100 units/mL in infants and children 10 kg of
weight or greater and in adults although no evidence is available to indicate longer patency of the
IO catheter when heparin is given.

● The duration of analgesic effect is typically less than one hour [66]. Redosing is accomplished by
administering half the initial lidocaine dose IO over 60 seconds.

● Provide systemic pain control (eg, fentanyl intraosseously) to patients with persistent pain during
IO infusion despite lidocaine administration.

TECHNIQUES — Intraosseous (IO) needles may be placed manually or with the assistance of
specifically designed devices.

Manual insertion technique — Manual insertion in the proximal tibia is generally difficult to perform
in patients over six years of age. The distal tibial site is preferred in older patients. A high quality video
is available in the reference to assist with learning the manual placement technique [68].

The following step-by-step technique for manual IO cannulation and removal assumes the use of the
proximal tibial location (figure 6 and figure 2) [44,69]:

● Placement
• Don a surgical mask, eye protection, and latex-free sterile gloves.

• Prepare the injection site with an antiseptic (eg, chlorhexidine or povidone iodine solution).

• If the child is awake, infiltrate the skin, subcutaneous tissue, and periosteum with 1 percent
lidocaine.

• Place the leg with knee extended in neutral position and then slightly externally rotate at the
hip to expose the flat part of the tibial surface, and externally rotate the foot.

• Check the needle to ensure that the bevels of the outer needle and the internal stylet are
properly aligned.

• Grasp the leg distally and lateral to the insertion site with the palm and fingers of the
nondominant hand to brace the leg against the force of IO placement and to prevent distal
leg movement during the procedure (figure 7). In infants and young children, the
nondominant hand may be placed above the site and wrap around the knee and thigh (figure
6). No portion of the stabilizing hand should rest behind the insertion site because this places
the operator at risk for needle-stick injury should the IO needle be inadvertently driven
completely through the extremity.

• Palpate the landmarks to identify the flat surface of the tibia approximately 1 to 2 cm below
and slightly (up to 1 cm) medial to the tibial tuberosity, and insert the IO needle through the
skin (figure 6).

• Direct the IO needle perpendicular to the entry site (figure 7 and figure 6) or, in skeletally
immature children, at a slight angle (10 to 15 degrees) from vertical (caudad for the proximal
tibia (figure 2); cephalad for the distal tibia or femur (figure 4 and figure 3)).

• Apply pressure with a twisting motion (figure 7). Avoid rocking the needle side to side which
may bend it or enlarge the access hole and lead to extravasation of fluid. As the needle
passes through the cortex and into the marrow cavity, a "give" or release of resistance is felt.
Clinicians not experienced in bone marrow needle insertion should understand that
considerable force is needed to introduce the needle into the bone marrow when traditional
methods are used (rather than a spring-loaded device or battery-powered driver). A back-
and-forth-twisting motion works best to pierce the bony cortex.

• Unscrew the needle cap and remove the stylet. If the needle has an adjustable flange,
carefully screw the flange down to the skin surface while stabilizing the needle.

• Confirm correct needle placement. (See 'Confirmation of placement' below.)

• Provide analgesia, as needed and depending upon patient status, by slow administration of
0.5 mg/kg lidocaine (2 percent [20 mg/mL] preservative-free formulation, maximum dose: 40
mg). (See 'Analgesia' above.)

• Once proper placement is confirmed, flush the needle with 10 mL of normal saline and
connect it to conventional IV tubing. Some clinicians prefer to flush once with heparinized
saline (10 units/mL in infants <10 kg and 100 units/mL in infants and children 10 kg of weight
 or greater and in adults although no evidence is available to indicate longer patency of the IO
catheter when heparin is given.

• Secure the bone marrow needle with tape and a dressing that does not obscure the needle
placement site so that infiltration can be rapidly detected. IO needles that are properly placed
are secure and not easily dislodged.

● Removal – Remove the needle by grasping the shaft and pulling up with a slight rotary motion.
Apply pressure to the IO site. Dress the site using aseptic technique.

Technical difficulties with manual IO needle placement usually decrease with experience and
familiarity with the procedure. Strategies to improve the success rate of IO needle placement
include emphasizing rotary motion, stabilizing the tubing and limb, monitoring continuously for
extravasation, and using strong, sharp needles [70].

Battery-powered driver — Battery-powered IO driver and needle sets are available for use in
children and adults (EZ-IO, VidaCare Corporation, Shavano Park, Texas, United States). The 15
gauge needles come in three lengths as follows:

● 15 mm (pink) for placement in patients weighing 3 to 39 kg

● 25 mm (blue) for placement in patients ≥40 kg with normal subcutaneous tissue

● 45 mm (yellow) for placement in patients ≥40 kg with excessive subcutaneous tissue

A high quality video is available in the reference to assist with learning the battery-powered driver
technique [68]. The needles may be inserted in the proximal or distal tibia, distal femur in infants and
children with limited subcutaneous tissue or, in skeletally mature adolescents and adults, the proximal
humerus [14,57,71]. (See 'Sites of placement' above.)

Placement and removal of the EZIO is performed as follows:

● Placement

• Identify the placement site based upon anatomic landmarks. (See 'Sites of placement'
above.)

• Don appropriate personal protective equipment and prepare the insertion site as for the
manual insertion technique. (See 'Manual insertion technique' above.)

• Ensure that the appropriate needle is selected based upon the patient’s weight and the
amount of subcutaneous tissue over the selected insertion site.

• Securely seat the needle on the battery-powered driver.

• Remove the needle safety cap.

• Position the driver with the needle at a 90 degree angle to the bone.

• Gently drive or manually press the needle until the tip touches the bone. Ensure that at least
5 mm of the catheter is visible above the skin at this point.
 • Squeeze the driver trigger and apply light but steady downward pressure to penetrate the
bone. Insufficient pressure may result in the needle not penetrating the bone.

• Release the trigger to stop insertion when a sudden decrease in resistance is felt (“give” or
“pop”) or when the appropriate depth, as indicated on the needle, is reached.

• Wait for the driver to stop spinning. Then, while holding the catheter in place, remove the
driver by pulling straight up from the catheter and unscrew the needle stylet by rotating it
counter-clockwise.

• Aspirate bone marrow to identify correct placement of the IO catheter and, if desired, to
obtain a sample for laboratory analysis using a syringe attached directly to the hub or the
manufacturer-provided extension set. (See 'Confirmation of placement' below and
'Diagnostic studies' above.)

• Provide analgesia, as needed and depending upon patient status, by slow administration of
0.5 mg/kg lidocaine (2 percent [20 mg/mL] preservative-free formulation, maximum dose: 40
mg). (See 'Analgesia' above.)

• Once proper placement is confirmed, secure the needle using tape and gauze or
manufacturer supplied fixation dressings( EZ_Stabilizer Dressing, VidaCare Corporation,
Shavano Park, Texas, United States). Flush the needle with 10 mL of normal saline using the
manufacturer-supplied IV connector tubing. Some clinicians prefer to flush once with
heparinized saline (10 units/mL in infants <10 kg and 100 units/mL in infants and children 10
kg of weight or greater and in adults although no evidence is available to indicate longer
patency of the IO catheter when heparin is given.

● Removal – Attach a Luer lock syringe to the catheter hub. While stabilizing the extremity, rotate
the catheter and syringe clockwise while pulling straight back. Apply pressure to the IO site.
Dress the site using aseptic technique.

Impact-driven devices — The impact-driven devices consist of the bone injection gun (BIG,
WaisMed Ltd, Houston, Texas, United States) and the FAST1 (Pyng Medical Corporation, Vancouver,
Canada).

Bone injection gun — The spring-loaded bone injection gun is available in sizes and automated
insertion depths suitable for patients over 12 years of age (blue casing, 15 gauge needle, insertion
depth 2.5 cm) and children from term newborn to 12 years of age (red casing, 18 gauge needle,
adjustable insertion depth 0.5 to 1.5 cm) [14,57,72].

A training video is available in the reference [72].

IO cannulation of the proximal tibia (all patients) or proximal humerus (skeletally mature adolescents
and adults) and removal is accomplished as follows:

● Placement

• Identify the placement site based upon anatomic landmarks. (See 'Sites of placement'
above.)
 • Don appropriate personal protective equipment and prepare the insertion site as for the
manual insertion technique. (See 'Manual insertion technique' above.)

• Choose the appropriate size bone injection gun (over 12 years of age: adult, term infant to 12
years of age: pediatric). In children, set the insertion depth using the marker located on the
device as follows:

- 0 to 3 years: 0.5 to 1 cm

- 3 to 6 years: 1 to 1.5 cm

- 6 to 12 years: 1.5 cm

• Place the device over the insertion site by holding the barrel at a 90 degree angle using the
nondominant hand.

• Squeeze the sides of the orange safety latch and remove it from the device using the
dominant hand. Save the safety latch for later use.

• While firmly holding the device in place with the nondominant hand, use the dominant hand
to deploy the needle by grasping under the wings of the device with two fingers and steadily
and gently pressing the palm against the top of the device. A “pop” will be heard when the
needle is successfully deployed.

• Remove the housing of the bone injection gun by pulling upward while rocking it gently from
side to side.

• Remove the stylet from the cannula.

• Place the safety latch around the cannula and tape it down to provide support.

• Aspirate bone marrow to identify correct placement of the IO catheter and, if desired, to
obtain a sample for laboratory analysis using a syringe attached directly to the hub or the
manufacturer provided extension set. (See 'Confirmation of placement' below and 'Diagnostic
studies' above.)

• Provide analgesia, as needed and depending upon patient status, by instillation of 0.5 mg/kg
lidocaine (2 percent [20 mg/mL] preservative-free formulation, maximum dose: 40 mg). (See
'Analgesia' above.)

• Once placement is confirmed, flush the IO catheter with 10 to 20 mL of normal saline through
an intravenous catheter connection set. Some clinicians prefer to flush once with heparinized
saline (10 units/mL in infants <10 kg and 100 units/mL in infants, children, and adults 10 kg
of weight or greater) although no evidence is available to indicate longer patency of the IO
catheter when heparin is given.

● Removal – Place the safety latch so that the IO catheter hub is seated in the square notch. If the
safety latch is not available, attach a Luer lock syringe. Pull upward with a slight rotary motion.
Apply pressure to the IO site. Dress the site using aseptic technique.
 FAST1 — The FAST1 is an impact-driven device designed for placement of an IO catheter (14
gauge and 155 mm in length) at a depth of 6 mm into the manubrium of patients ≥12 years of age
through the use of manual pressure [57,73]. A training video is available in the reference [74].

IO catheter placement and removal in the sternum is performed as follows:

● Placement

• Expose the upper sternum and ensure that there is no evidence of trauma to it.

• Don appropriate personal protective equipment and prepare the insertion site as for the
manual insertion technique using chlorhexidine or iodine and isopropyl alcohol provided in
the device package. (See 'Manual insertion technique' above.)

• Remove the target patch from the package and remove the first backing (labeled “1”).

• Identify the sternal notch and place a finger perpendicular to the notch. Apply the patch
notches against the finger while maintaining alignment of the patch with the sternal notch.

• Remove the bottom half of the backing (labeled “2”) and secure the patch to the patient’s
sternum and chest.

• Ensure that the clear “target zone” is centered over the manubrium (upper sternum).

• Remove the sharps plug and introducer from the package.

• Remove the clear sharps cap from the introducer.

• Confirm alignment of the target patch and then, while firmly holding the introducer
perpendicular to the manubrium, place the bone probe needles into the circular target zone.

• Push down on the introducer steadily while maintaining perpendicular force to the
manubrium until the handle separates from the assembly with a “pop”.

• Remove the introducer assembly with bone probe needles and use the sharps plug and clear
sharps cap to secure the sharps safely.

• Remove the blue cap from the IO catheter and connect the infusion tube to the friction
connector on the tubing attached to the target patch.

• Remove the white cap from the Luer fitting of the target patch infusion tubing.

• Aspirate bone marrow to identify correct placement of the IO catheter and, if desired, obtain
a sample for laboratory analysis. (See 'Confirmation of placement' below and 'Diagnostic
studies' above.)

• Provide analgesia, as needed and depending upon patient status, by instillation of 0.5 mg/kg
lidocaine (2 percent [20 mg/mL] preservative-free formulation, maximum dose: 40 mg). (See
'Analgesia' above.)

• Flush the IO catheter with 10 to 20 mL of normal saline through an intravenous catheter

 connection set. Some clinicians prefer to flush once with heparinized saline (10 units/mL in
infants <10 kg and 100 units/mL in infants, children, and adults 10 kg of weight or greater)
although no evidence is available to indicate longer patency of the IO catheter when heparin
is given.

• Secure the protector dome directly over the target patch.

● Removal – While holding the target patch against the skin, peel away the protector dome.
Disconnect the infusion tube. Grasp the infusion tube close to the skin with fingers or a hemostat
and pull upwards perpendicular to the manubrium until the infusion tube, including the metal tip is
removed from the chest. Remove the target patch and apply pressure to the infusion site. Dress
the site using aseptic technique.

Confirmation of placement — The following findings indicate correct placement of the IO cannula:

● The needle or catheter stands firmly on its own within the bone.

● Bone marrow is obtained with aspiration of the needle or catheter, although this may not always
occur even with a properly placed IO needle or catheter.

● Flushing of the needle or catheter occurs without evidence of extravasation. Resistance to

flushing is expected because, unlike a vein, the bone marrow cavity is not distensible.

Correct placement in the bone marrow cavity can also be confirmed radiologically using a mini C-arm
fluoroscopic imaging device or bedside Doppler ultrasound [75,76]. Doppler ultrasound can also
identify incorrect positioning indicated by extravasation of fluid around the IO needle or catheter.

DURATION OF USE — Intraosseous (IO) cannulation provides rapid temporary vascular access. An
IO needle should be replaced with a venous line as soon as possible. In one retrospective series
describing 58 IO placements in children requiring critical care transport, IO needles were left in place
for a mean of 5.2 hours (range 10 minutes to 36 hours) [58]. The only reported complications were
local edema and infiltration, occurring in 12 percent of patients. Prolonged IO infusions beyond 24
hours are associated with an increased risk of osteomyelitis [77].

COMPLICATIONS — Intraosseous (IO) cannulation is considered to be relatively safe, with a rate of

serious complications of less than 1 percent [5,78]. Potential problems include tibial fracture,
compartment syndrome, skin necrosis, osteomyelitis, and subcutaneous abscess. Theoretical long-
term complications include damage to the bone marrow and disturbance in growth of the bone, as well
as fat embolism.

● Bilateral tibial fractures have been described in a single case of a three-month-old infant for
whom attempts at IO cannulation using a large bore needle were unsuccessful [78].

● Infusion of fluids into the subcutaneous tissue has caused compartment syndrome and resulted in
amputation of an extremity [79]. Osteomyelitis is a rare complication. A review of the publications
describing 4270 IO infusions found only 27 cases (0.6 percent) of osteomyelitis [77]. Most
reported infections occurred when the needle remained in place for more than 24 hours. One
observational study from 1940 suggested an increased risk of osteomyelitis with infusion of
hypertonic fluids, but this association has not been subsequently validated [4].
 ● No long-term effects on tibial growth were found in a prospective study of 23 children with mean
follow-up of 29 months [80]. A smaller study had similar results [81]. Follow-up studies of bone
and bone marrow after IO infusions in experimental models also have shown only short-term
periostitis and no or minimal long-term sequelae on bone marrow or bone growth [82-84]. The
metaphyseal changes after insertion of a bone marrow needle resolve by three weeks [83].

● Microscopic fat and bone marrow emboli were found in the pulmonary autopsy specimens of two
children who received IO infusion during resuscitation attempts and in 100 percent of study
subjects in several animal studies of IO infusion [54,55]. However, the clinical relevance of these
emboli is not clear. No significant alterations in arterial oxygenation were noted, nor any
intrapulmonary shunting, during a four-hour study period, despite the universal finding of fat and
bone marrow emboli [54].

● The only reported deaths resulting from IO infusions were associated with the sternal approach
using a manual technique. These deaths were from mediastinitis, hydrothorax, and cardiac or
great vessel injury [85].

ADDITIONAL RESOURCES — Videos are available in the references to assist with learning
techniques for intraosseous cannulation:

● Manual placement [68]

● Battery-powered driver technique [68]

● Bone injection gun [72]

● Fast1 [74]

SUMMARY AND RECOMMENDATIONS

● Intraosseous (IO) cannulation provides intravascular access via the medullary sinuses in the
bone marrow of long bones (figure 1). These veins, supported by the bony matrix, do not collapse
in patients with shock or hypovolemia. (See 'Anatomy' above.)

● We recommend that infants and children in cardiopulmonary arrest or severe shock who do not
have readily available intravenous access undergo IO cannulation for medication administration,
fluid therapy, and diagnostic studies rather than percutaneous central venous line placement or
surgical venous cutdown (Grade 1A). (See 'Indications' above.)

● We suggest that adults in cardiopulmonary arrest or severe shock who do not have readily
available intravenous access undergo IO cannulation for medication administration, fluid therapy,
and diagnostic studies rather than percutaneous central venous line placement or surgical
venous cutdown (Grade 2B). We emphasize that an IO needle be flushed before and after
medication administration if fluids are not already infusing. (See 'Indications' above.)

● IO cannulation may also be appropriate in patients with emergent or urgent conditions where
reliable venous access cannot be achieved quickly (eg, shock, sepsis, status epilepticus,
extensive burns, multiple trauma) or in patients for whom intravascular access is medically
necessary and cannot be achieved by other means.
 ● IO cannulation should not be performed in fractured bones, bones with a prior failed IO placement
attempt, or in extremities with vascular disruption. IO access also should be avoided in patients
with osteogenesis imperfecta, osteopetrosis, right to left congenital cardiac shunts, or those with
burns or infection near the access site. (See 'Contraindications' above.)

● We recommend that all patients who undergo IO placement for life-threatening illnesses (eg,
cardiac arrest) have the first attempt made at the proximal tibial site, unless otherwise
contraindicated (Grade 1B). Preferred alternative sites vary based upon the age and skeletal
maturity of the patient (table 1). A battery-powered or impact driven device is typically required to
accomplish IO placement in the proximal tibia of patients over six years of age. If such a device is
not available, the clinician should attempt manual placement at the medial or lateral malleolus in
older patients. (See 'Sites of placement' above.)

● We suggest that, in infants under one year of age, clinicians use manual needles or battery-
powered devices for IO insertion rather than an impact-driven device (Grade 2C). (See 'Choice of
device' above and 'Techniques' above.)

● We suggest that, in children ≥1 year of age, adolescents, and adults, clinicians use a battery-
powered device for IO placement, if available, rather than a manual needle or impact-driven
device (Grade 2B). (See 'Choice of device' above and 'Techniques' above.)

● In critically ill children and adults who require immediate vascular access (eg, patients in arrest or
severe shock), IO placement is performed without analgesia. These patients may receive
systemic analgesia (eg, fentanyl intraosseously) or infusion of preservative-free lidocaine, if they
become responsive to pain once the IO is placed and as tolerated by their clinical condition. (See
'Analgesia' above.)

● In awake patients for whom IO placement is in response to difficulty with peripheral venous
access and whose condition is not emergent, we suggest analgesia for IO placement be provided
by local infiltration of anesthetic at the IO site and administration of preservative-free lidocaine
through the IO cannula prior to infusion of medications, fluids, or blood products (Grade 2C).
(See 'Analgesia' above.)

● Analgesia for the pain associated with the IO infusion itself may be obtained by slowly
administering 0.5 mg/kg preservative-free lidocaine 2 percent (20 mg/mL, maximum dose: 40 mg)
over one minute through the IO catheter prior to flushing and drug administration. Systemic
analgesia (eg, fentanyl intraosseously, as tolerated) is an alternative method of analgesia for IO
infusion and can be provided to patients with persistent pain during infusion despite
administration of intravenous lidocaine. Local infiltration of anesthetic at the IO insertion site may
not be necessary in adolescents and adults when using a battery-powered driver. (See
'Indications' above and 'Analgesia' above.)

● Videos are available in the references to assist with learning techniques for IO cannulation. (See
'Additional resources' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Pamela Bailey,
MD, who contributed to an earlier version of this topic review.
 Use of UpToDate is subject to the Subscription and License Agreement.

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Topic 6321 Version 19.0

GRAPHICS

Venous drainage from marrow of long bone with

intramedullary needle in place

The veins that drain the medullary sinuses of the long bones are supported
by the bony matrix. They do not collapse in shock or hypovolemia.

Reproduced with permission from: Barkin RM (Ed). Pediatric emergency medicine:

Concepts and clinical practice, 2nd ed, Mosby, St. Louis, 1997. p.151. Copyright ©
1997 Mosby.

Graphic 77643 Version 4.0

Intraosseous cannula placement site by patient age

Patient age Intraosseous site

Infant (under 1 year) Proximal tibia

Distal femur

Child (1-12 years) Proximal tibia*

Distal tibia or fibula

Skeletally immature adolescent ¶ (12-18 years) Proximal tibia*

Distal tibia or fibula

Sternum Δ

Over 18 years Proximal tibia*

Proximal humerus ◊

Distal tibia or fibula

Sternum Δ

* Battery-powered or impact-driven devices are typically required to place an intraosseous cannula through
the bony cortex of the proximal tibia in patients older than six years of age.
¶ Age at full skeletal maturity varies according to gender and individual patient characteristics.
Δ Sternal intraosseous cannula placement should only be attempted using devices specifically designed for
that placement site.
◊ The proximal humerus site should only be used in skeletally mature patients.

Graphic 53119 Version 5.0

Proximal tibial intraosseous access site

Entry site at the proximal tibia.

Reproduced with permission from: Hodge Dee III. Intraosseous infusion. In: Textbook of
Pediatric Emergency Procedures, 2nd ed, King C, Henretig FM (Eds), Lippincott Williams &
Wilkins, Philadelphia 2008. Copyright © 2008 Lippincott Williams & Wilkins. www.lww.com.

Graphic 67266 Version 10.0

Femoral intraosseous access site

Entry site at the distal femur.

Reproduced with permission from: Hodge Dee III. Intraosseous infusion. In:
Textbook of Pediatric Emergency Procedures, 2nd ed, King C, Henretig FM (Eds),
Lippincott Williams & Wilkins, Philadelphia 2008. Copyright © 2008 Lippincott
Williams & Wilkins. www.lww.com.

Graphic 56412 Version 10.0

Distal tibial intraosseous access site

Entry site at the distal tibia.

Reproduced with permission from: Hodge Dee III. Intraosseous infusion. In:
Textbook of Pediatric Emergency Procedures, 2nd ed, King C, Henretig FM (Eds),
Lippincott Williams & Wilkins, Philadelphia 2008. Copyright © 2008 Lippincott
Williams & Wilkins. www.lww.com.

Graphic 51195 Version 10.0

Proximal humeral intraosseous access site

For proximal humeral intraosseous placement in the skeletally mature adolescent or adult,
adduct and internally rotate the arm (hand on abdomen) to make damage to the medial
structures of the axillary plexus unlikely. Find the greater tubercle of the proximal humerus
approximately 2 cm below the acromion process. Alternatively, palpate the greater
tubercle from below. Access the intraosseous space using a battery operated drill.

Graphic 57495 Version 3.0

Intraosseous cannulation technique

(A) Insert the needle in the proximal tibia on the flat surface located distal and medial to the
tibial tuberosity. Direct the needle caudad (away from growth plate) at a 10 to 15 degree
angle. Use downward pressure from the heel of the hand, and a twisting motion until
resistance decreases. See text for details.
(B) Marrow can sometimes be aspirated.
(C) The needle will flush easily when it is in the marrow cavity and should stand without
support.
Once successful placement is established, immobilize the leg and secure the needle.

Graphic 81759 Version 5.0

Manual intraosseous needle placement

(A) The needle is angled slightly away from the joint space or, as some more recent
sources have recommended, perpendicular to the bone.
(B) A back-and-forth "screwing" motion is used to insert the needle. "Rocking" the
needle from side to side results in enlargement of the puncture site and extravasation
of infused fluid.
(C) Intramedullary placement is confirmed by aspirating marrow.

Reproduced with permission from: Hodge D III. Intraosseous infusion. In: Textbook of
Pediatric Emergency Procedures, 2nd Edition, King C, Henretig FM, Eds. Lippincott Williams &
Wilkins, 2008. Copyright © 2008 Lippincott Williams & Wilkins. www.lww.com.

Graphic 68441 Version 7.0

Contributor Disclosures
Catherine E Perron, MD Nothing to disclose Anne M Stack, MD Nothing to disclose Allan B
Wolfson, MD Nothing to disclose James F Wiley, II, MD, MPH Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found,
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