Intraosseous infusion

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Intraosseous infusion
Infusion devices.jpg
Two pictures of the EZ IO device.
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Intraosseous infusion (IO) is the process of injecting directly into the marrow of a bone to provide a non-collapsible entry point into the systemic venous system.[1] This technique is used to provide fluids and medication when intravenous access is not available or not feasible. A comparison of intravenous (IV), intramuscular (IM), and intraosseous (IO) routes of administration concluded that the intraosseous route is demonstrably superior to intramuscular and comparable to intravenous administration (in delivering paediatric anaesthetic drugs).[2] This route of fluid and medication administration is an alternative one to the preferred intravascular route when the latter cannot be established in a timely manner.


This American Heart Association guideline cited two randomized controlled trials, one of 60 children[3] and one of electively cannulated hematology/oncology patients.[4] In addition, uncontrolled studies have been performed,[5][6] one of which reported 72% to 87% rates of successful insertion.[5]


NIO IO device
BIG IO devices
Axial CT with left humeral head EZ IO infusion of contrast.

The needle is injected through the bone's hard cortex and into the soft marrow interior which allows immediate access to the vascular system. An IO infusion can be used on adult or pediatric patients when traditional methods of vascular access are difficult or otherwise cause unwanted delayed management of the administration of medications. Each IO device has different designed locations, but the most common site of insertion is the antero-medial aspect of the upper, proximal tibia as it lies just under the skin and can easily be palpated and located. The anterior aspect of the femur, the superior iliac crest and the head of the humerus are other sites that can be used.[7] The IO needle is then positioned at a 90 degree angle to the injection site, and the needle is advanced through manual traction, impact driven force, or power driven.[8] The site of injection can be maintained for 24–72 hours, after which another route of access should be obtained to prevent the risk of an infection at the site.[9]

Intraosseous infusion is contraindicated when there is a possibility that the potential site of injection has a known, or suspected fracture, appears to be visibly infected, or is burned. Medical conditions that might also preclude the use of intraosseous infusion include osteopenia, osteopetrosis, and osteogenesis imperfecta as fractures are more likely to occur.[8] The procedure also only allows for one attempt per bone meaning another route of infusion much be secured, or a different bone chosen.[8]

Although intravascular access is still the preferred method for medication delivery in the prehospital area, IO access for adults has become more common. As of 2010, American Heart Association no longer recommends using the endotracheal tube for resuscitation drugs, except as a last resort when IV or IO access cannot be gained.[10] The IO is becoming more and more common in civilian and military based pre-hospital emergency medical services (EMS) systems around the world.[11] Intraosseous access has roughly the same absorption rate as IV access, and allows for fluid resuscitation as well as high-volume drugs such as sodium bicarbonate to be administered in the setting of a cardiac arrest when IV access is unavailable.[8] Endotracheal administration allows only specific drugs that have relatively low toxicity to lung tissue, and must be restricted to relatively low volumes to avoid drowning the patient.


The automatic intra-osseous devices allow quick and safe access to the patient's vascular system for fluid and drug administration. There are several FDA approved IO devices: The BIG Bone Injection Gun and The NIO New Intra Osseous device are automatic intra-osseous infusion device used by military and civilian healthcare systems; the battery-powered EZ-IO and hand-powered Fast1, Fast Combat and Fast Responder. Other devices include the Cook IO needle and the Jamshidi 15G.

There have been several studies comparing the EZ-IO and the BIG.[12][13][14] Another paper compared the EZ-IO with the Cook IO needle.[15]


  1. ^ Tobias JD, Ross AK (2010). "Intraosseous infusions: a review for the anesthesiologist with a focus on pediatric use". Anesthesia & Analgesia. 110 (2): 391–401. PMID 19897801. doi:10.1213/ane.0b013e3181c03c7f. 
  2. ^ Moore GP, Pace SA, Busby W (1989). "Comparison of intraosseous, intramuscular, and intravenous administration of succinylcholine". PEDIATRIC EMERGENCY CARE. 5 (4): 209–210. PMID 2602189. doi:10.1097/00006565-198912000-00001. 
  3. ^ Banerjee S, Singhi SC, Singh S, Singh M (1994). "The intraosseous route is a suitable alternative to intravenous route for fluid resuscitation in severely dehydrated children". Indian pediatrics. 31 (12): 1511–20. PMID 7875811. 
  4. ^ Brickman KR, Krupp K, Rega P, Alexander J, Guinness M (1992). "Typing and screening of blood from intraosseous access". Annals of Emergency Medicine. 21 (4): 414–7. PMID 1554180. doi:10.1016/S0196-0644(05)82661-7. 
  5. ^ a b Frascone RJ, Jensen JP, Kaye K, Salzman JG (2007). "Consecutive field trials using two different intraosseous devices". Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 11 (2): 164–71. PMID 17454802. doi:10.1080/10903120701205851. 
  6. ^ Davidoff J, Fowler R, Gordon D, et al. (2005). "Clinical evaluation of a novel intraosseous device for adults: prospective, 250-patient, multi-center trial". Journal of Emergency Medical Services. 30 (10): suppl 20–23. PMID 16382512. 
  7. ^ Dubick, M. A.; Holcomb, J. B. (2000-07-01). "A review of intraosseous vascular access: current status and military application". Military Medicine. 165 (7): 552–559. ISSN 0026-4075. PMID 10920658. 
  8. ^ a b c d Luck, Raemma P.; Haines, Christopher; Mull, Colette C. "Intraosseous Access". The Journal of Emergency Medicine. 39 (4): 468–475. doi:10.1016/j.jemermed.2009.04.054. 
  9. ^ Vreede E, Bulatovic A, Rosseel P, Lassalle X (December 1, 2000). "Intraosseous Infusion" (PDF). Update in Anaesthesia. World Federation of Societies of Anaesthesiologists. 12: 38–40. ISSN 1353-4882. Retrieved 2010-07-03. 
  10. ^ Neumar, Robert W.; Otto, Charles W.; Link, Mark S.; Kronick, Steven L.; Shuster, Michael; Callaway, Clifton W.; Kudenchuk, Peter J.; Ornato, Joseph P.; McNally, Bryan (2010-11-02). "Part 8: Adult Advanced Cardiovascular Life Support". Circulation. 122 (18 suppl 3): S729–S767. ISSN 0009-7322. PMID 20956224. doi:10.1161/CIRCULATIONAHA.110.970988. 
  11. ^ Paxton, James H.; Knuth, Thomas E.; Klausner, Howard A. "Proximal Humerus Intraosseous Infusion: A Preferred Emergency Venous Access". The Journal of Trauma: Injury, Infection, and Critical Care. 67 (3): 606–611. doi:10.1097/ta.0b013e3181b16f42. 
  12. ^ Demir OF1, Aydin K, Akay H, Erbil B, Karcioglu O, Gulalp B. (July 2014). "Comparison of two intraosseous devices in adult patients in the emergency setting: a pilot study". Eur J Emerg Med. PMID 25075979. doi:10.1097/MEJ.0000000000000187. 
  13. ^ Leidel BA, Kirchhoff C, Braunstein V, Bogner V, Biberthaler P, Kanz KG (August 2010). "Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: A prospective, randomized study". Resuscitation. 81 (8): 994–9. PMID 20434823. doi:10.1016/j.resuscitation.2010.03.038. 
  14. ^ Shavit I, Hoffmann Y, Galbraith R, Waisman Y (September 2009). "Comparison of two mechanical intraosseous infusion devices: a pilot, randomized crossover trial". Resuscitation. 80 (9): 1029–33. PMID 19586701. doi:10.1016/j.resuscitation.2009.05.026. 
  15. ^ Brenner T, Bernhard M, Helm M, et al. (September 2008). "Comparison of two intraosseous infusion systems for adult emergency medical use". Resuscitation. 78 (3): 314–9. PMID 18573590. doi:10.1016/j.resuscitation.2008.04.004. 

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