Intraosseous infusion

Intraosseous infusion in cases where it is necessary to ensure access to the bloodstreamn which cannot be ensured even with a line. All drugs, including solutions and blood derivatives, can be administered intraosseously. The speed of onset of action is comparable to central venous access. It is most often used in pre-hospital care, in hospitals it can help in urgent situations, especially if it is not possible to cannulate the central vein reliably and quickly.

A certain disadvantage is the painful application, the need for special cannulae and the limited time of possible use - 6-12, exceptionally a maximum of 24 hours of use are mentioned. The pain during bone penetration is overestimated, it is comparable or less than skin puncture with a wider cannula (Gronych 2014).

Indication

impossibility of inserting an intravenous cannula (two unsuccessful attempts in an emergency situation)
cardiopulmonary resuscitation
shock of any etiology
status epilepticus

Intraosseous Infusion

Contraindications

osteogenesis imperfecta
osteopetrosis
fractura tibiae or other bones chosen for puncture
patient refusal
injection site infection, previous orthopedic surgery
intra-abdominal and pelvic injuries from intended bony entry in the inferior vena cava basin

approches

- humeral head (suitable for resuscitation)
- proximal part of the tibia at the site of tuberositas tibiae (children < 6 years)
- distal femur
- calcaneus (newborns and children < 6 months)

proximal tibial procedure

- the patient is in the supine position
- We support the slightly bent lower limb so that the lower leg rests on a firm base (i.e. to ensure good stabilization of the lower leg)
the injection site is the proximal part of the tibia, approximately 2 cm medial and 2 cm proximal (distal in children) from the tuberositas tibiae , strict aseptic conditions must be ensured during the procedure
perpendicular to the long axis of the bone, we penetrate the bone matrix and penetrate the bone marrow with a helical movement (penetration into it is associated with a loss of resistance), the depth of injection is usually 1-1.5 cm

After introducing

jehla je ve správné poloze, když pevně stojí v kosti a když při aspiraci nasáváme dřeň
u pacienta při vědomí aplikujeme velmi pomalu 2 ml lokálního anestetika
pokud si myslíme, že jsme ve správné poloze, ale kostní dřeň nelze nasát, propláchneme jehlu 10 ml (děti 2 – 5 ml) fyziologického roztoku a sledujeme, zda nevzniká vyklenutí
první bolus razantně během 5 s k rozvolnění trámčiny kosti (No flush = no flow)
pokud je vše bez problémů, jehlu fixujeme a sterilně kryjeme

Complications

povrchové infekce
osteomyelitis
subperiostální infúze
compartment syndrome
přechodné objevení blastů v periferní krvi
dislokace jehly a následné krvácení
podle některých autorů u dospělých pacientů tuková embolie
poškození růstové chrupavky u dětí

Video

<mediaplayer width='500' height='300'>https://www.youtube.com/watch?v=KHXSfh2ZRDM</mediaplayer>

Intraosseous infusion

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