Atlas of Procedures in Neonatology, 4th Edition

Miscellaneous Procedures


Intraosseous Infusions

Mary E. Revenis

  1. Indications
  2. Emergency intravenous access when other venous access is not readily available; to restore intravascular volume so that peripheral venous access becomes possible. See Table 47.1 for categories of fluid that have been infused (1,2,3 and 4).
  3. Contraindications (3,5,6)
  4. Bone without cortical integrity (fracture, previous penetration): Extravasation of infusate
  5. Sternal site: Potential damage to heart and lungs (7)
  6. Overlying soft tissue infection
  7. Osteogenesis imperfecta
  8. Obliterative diseases of marrow such as osteopetrosis
  9. Equipment


  1. Surgical gloves
  2. Cup with antiseptic solution
  3. Gauze squares
  4. Aperture drape
  5. 1% lidocaine in 1-mL syringe with 25-gauge needle
  6. Needle, in order of preference (1,2,3,8)
  7. Bone marrow or intraosseous needle (18-gauge) (stylet and adjustable depth indicator preferred)
  8. Short spinal needle with stylet (18- or 20-gauge)
  9. Short hypodermic needle (18- or 20-gauge)
  10. Butterfly needle (16- to 19-gauge)
  11. 5-mL syringe on a three-way stopcock and IV extension set with clamp
  12. Syringes with saline flush solution
  13. Intravenous infusion set and intravenous fluid


  1. Small sand bag or rolled towel to aid in stabilizing limb
  2. Tape
  3. Armboard
  4. Disposable plastic cup


Intraosseous needle placement device (intended for use at the proximal tibial location). Devices approved for newborns are the spring-activated B.I.G. Bone Injection Gun (Waismed, Houston, TX, USA) and the battery operated driver EZ-IO Pediatric (Vidacare, San Antonio, TX, USA). Information on use of these devices in premature infants is scarce and as yet unpublished. It is not known if the incidence of success or complications using these devices differs compared to manual insertion of the intraosseous needle.

  1. Precautions
  2. Limit use to emergency vascular access, when peripheral or central venous access is not feasible.
  3. Avoid inserting needle through infected skin or subcutaneous tissue.
  4. Stabilize limb with counterpressure, with sand bag or towel roll directly opposite proposed site of penetration, to avoid bone fracture.
  5. If hand is used to stabilize limb, do not position hand behind puncture site, to avoid inadvertent puncture of hand by the intraosseous needle if it goes through the limb. This is true regardless of whether a sand bag or towel is used. It is at times helpful to use the hand to help stabilize the limb, but it must be done without injury to the practioner.
  6. Limit needle size to decrease chance of fracture of bone.
  7. Administer drugs in the usual doses for intravenous administration; however, when possible, dilute hypertonic or strongly alkaline solutions prior to infusion, to reduce risk of bone marrow damage (2).
  8. Discontinue intraosseous infusion as soon as alternative venous access is established, to reduce risk of osteomyelitis.
  9. Technique

Proximal tibia (1,2,3,9,10) (Fig. 47.1)

  1. Position patient supine.
  2. Place sand bag or towel roll behind knee to provide countersupport behind puncture site.
  3. Clean proximal tibia with antiseptic solution.
  4. Put on sterile gloves.


TABLE 47.1 Types of Intraosseous Infusates Reported in the Literature (4,15,17,21)

1. Fluids

1. Normal saline

2. Crystalloids

3. Glucose (dilute if possible when using D50) (15,22)

4. Ringer's lactate (17)

2. Blood and blood products

3. Medications

1. Anesthetic agents

2. Antibiotics

3. Atropine (17)

4. Calcium gluconate

5. Dexamethasone (17)

6. Diazepam (17)

7. Diazoxide (17); phenytoin (23)

8. Dobutamine (21)

9. Dopamine (21,22,24)

10.   Ephedrine (25)

11.   Epinephrine (25)

12.   Heparin (17)

13.   Insulin

14.   Isoproterenol (24)

15.   Lidocaine

16.   Morphine

17.   Sodium bicarbonate (dilute if possible) (15,26)

4. Contrast material (27)

  1. Apply aperture drape.
  2. If appropriate, inject lidocaine into skin, soft tissue, and periosteum (11).
  3. Determine penetration depth on needle: Rarely more than 1 cm in infants.
  4. For needle or bone needle injection device with adjustable depth indicator, adjust sheath to allow desired penetration.
  5. For needle without an adjustable depth indicator, hold the needle in the dominant hand with blunt end supported by the palm and the index finger approximately 1 cm from the bevel of the needle, to avoid pushing it past this mark.
  6. Palpate tibial tuberosity with index finger.

FIG. 47.1. A: Anterior view. B: Sagittal section. C: Cross section through tibia.

  1. Hold the thigh and knee above and lateral to the insertion site with the palm of the nondominant hand. Wrap fingers and thumb around the knee to stabilize the proximal tibia.
  2. Insert needle on the flat, anteromedial surface of the tibia, 1 to 2 cm below the tibial tuberosity.
  3. Direct needle at an angle of 10 to 15 degrees toward the foot, to avoid the growth plate.
  4. Advance needle.

 .   For manual insertion, advance needle using firm pressure with a twisting motion until there is a sudden, slight decrease in resistance, indicating puncture of the cortex.

  1. If an automatic spring-activated intraosseous needle injection device is used, hold the cylinder against the puncture site at a 90-degree angle with one hand. Release the safety latch on the cylinder with the other hand. Depress the cylinder, as with a syringe, without the use of force.
  2. If a battery-operated driver with attached needle is utilized, hold the driver in the dominant hand. Position the needle against the puncture site at a 90-degree angle. Depress the trigger to activate the driver. Do not force the driver, but apply firm, steady pressure, allowing the driver to insert the needle. Stop when there is a sudden decrease in resistance.
  3. Do not advance the needle beyond cortical puncture.
  4. Remove the stylet.
  5. Confirm the position of the needle in the marrow cavity.

 .   Needle should stand without support.

  1. Securely attach a 5-mL syringe and attempt to aspirate blood or marrow. Aspiration is not always successful when using an 18- or 20-gauge needle.
  2. If bone marrow is aspirated, it can be analyzed for blood chemistry values, partial pressure of arterial carbon dioxide, pH, hemoglobin level (12,13), type and cross-match, or cultured (13).



  1. Attach syringe of saline flush solution and infuse 2 to 3 mL slowly, while palpating the tissue adjacent to the insertion site to detect extravasation. There should be only mild resistance to fluid infusion.
  2. If marrow cannot be aspirated and significant resistance to fluid infusion is met:

 .   The hollow bore needle may be obstructed by small bone plugs.

  1. Reintroduce the stylet, or
  2. Introduce a smaller-gauge needle through the original needle.
  3. Attach syringe of saline flush and flush 2 to 3 mL of fluid.
  4. The bevel of the needle may not have penetrated the cortex.
  5. Redetermine estimated depth needed.
  6. Advance.
  7. Flush with saline.
  8. The bevel of the needle may be lodged against the opposite cortex.
  9. Withdraw needle slightly.
  10. Flush with saline.
  11. Observe the site for extravasation of fluid, indicating that:

 .   The placement is too superficial, or

  1. The bone has been penetrated completely.
  2. If extravasation occurs, withdraw needle and select a different bone.
  3. When needle position is confirmed:

 .   Attach syringe and infuse medications or fluid directly into the needle or via an IV extension set with clamp. Clear medications with saline flush.

  1. For continuous infusion, attach a standard intravenous infusion set with an infusion pump to the intraosseous needle and administer at the same rate as for IV infusion (2).
  2. Secure intraosseous needle and maintain a clean infusion site while the needle is in place.

 .   Tape the flanges of the needle to the skin to prevent dislodgement. If a needle safety latch is provided, attach the latch and then apply tape.

  1. If desired, cover the exposed end of the needle with a disposable cup, taping the cover down. Cutting off the bottom of the cup will aid in visualization of the site for monitoring.
  2. Secure intravenous tubing with tape to the leg.
  3. Secure the leg to the armboard.
  4. Obtain radiograph to confirm position of needle and to rule out fracture.

FIG. 47.2. Intraosseous infusion into the distal tibia. [Reproduced with permission from 

Spivey WH. Intraosseous infusions. J Pediatr. 1987;111(5):639


  1. Discontinue intraosseous infusion as soon as alternative intravenous access is achieved.

In an infant with hypotension/hypovolemia, infusion via the interosseous route can restore peripheral perfusion to a point at which venous access is possible in well under 30 minutes.

 .   Remove needle.

  1. Apply a sterile dressing over the puncture site.
  2. Apply pressure to the dressing for 5 minutes.

Distal tibia (2,8) (Fig. 47.2)

  1. Position patient supine.
  2. Prepare site and needle as for proximal tibia.
  3. Insert needle in the medial surface of the distal tibia just proximal to the medial malleolus.
  4. Direct needle cephalad away from the joint space.
  5. Proceed as for proximal tibia.

Distal femur (1,3,9) (Fig. 47.1)

  1. Position patient supine.
  2. Place sand bag or towel roll behind knee.
  3. Prepare site and needle as for proximal tibia.
  4. Insert needle 1 to 3 cm above the external condyles in the anterior midline.
  5. Direct needle cephalad at an angle of 10 to 15 degrees.
  6. Proceed as for proximal tibia.
  7. Complications (1,4,14,15)
  8. Fracture of bone (16)
  9. Complete penetration of bone (17)



  1. Osteomyelitis (14,15)
  2. Periostitis (15)
  3. Subcutaneous abscess
  4. Cellulitis
  5. Sepsis
  6. Extravasation of fluid from the puncture site
  7. Subperiosteal or subcutaneous infiltration or hematoma
  8. Compartment syndrome (18)
  9. Subcutaneous sloughing
  10. Death (reported only with sternal bone site) (7)
  11. Theoretical (as yet unreported) (19,20)
  12. Embolization of bone fragments or fat
  13. Damage to bone marrow
  14. Damage to growth plate


  1. Fiser D.Intraosseous infusion. N Engl J Med. 1990;322:1579.
  2. Spivey W.Intraosseous infusions. J Pediatr. 1987;111:639.
  3. Hodge D.Intraosseous infusions: review. Pediatr Emerg Care. 1985;1:215.
  4. Ellemunter H, Simma B, Trawoger R, Maurer H.Intraosseous lines in preterm and full term neonates. Arch Dis Child Fetal Neonatal Ed. 1999;80:F74.
  5. Manley L, Haley K, Dick M.Intraosseous infusion: rapid vascular access for critically ill or injured infants and children. J Emer Nurs.1988;14:63.
  6. Miner WF, Corneli HM, Bolte RG, et al. Prehospital use of intraosseous infusion by paramedics. Pediatr Emerg Care.1989;5:5.
  7. Turkel H.Deaths following sternal puncture. JAMA. 1954;156:992.
  8. Iserson K, Criss E.Intraosseous infusions: a usable technique. Am J Emerg Med. 1986;4:540.
  9. Carlson DW, DiGuilio GA, Givens TG, et al. Illustrated techniques of pediatric emergency procedures. In: Fleisher G, Ludwig S, Henretig FM, eds. Textbook of Pediatric Emergency Medicine.5th ed. Philadelphia: Lippincott Williams & Wilkins; 2006:1879.
  10. Parrish G, Turkewitz D, Skiendzielewski J.Intraosseous infusions in the emergency department. Am J Emerg Med. 1986;4:59.
  11. Mofenson HC, Tascone A, Caraccio TR.Guidelines for intraosseous infusions. J Emerg Med. 1988;6:143.
  12. Johnson L, Kissoon N, Fiallos M, et al. Use of intraosseous blood to assess blood chemistries and hemoglobin during cardiopulmonary resuscitation with drug infusions. Crit Care Med.1999;27:1147.
  13. Orlowski JP, Porembka DT, Gallagher JM, VanLente F.The bone marrow as a source of laboratory studies. Ann Emerg Med.1989;18:1348.
  14. Rosetti V, Thompson B, Miller J, et al. Intraosseous infusion: an alternative route of pediatric intravascular access. Ann Emerg Med.1985;14:885.
  15. Heinild S, Sondergaard J, Tudvad F.Bone marrow infusions in childhood: experiences from a thousand infusions. J Pediatr.1947;30:400.
  16. La Fleche F, Slepin M, Vargas J, Milzman D.Iatrogenic bilateral tibial fractures after intraosseous infusion attempts in a 3-month-old infant. Ann Emerg Med. 1989;18:1099.
  17. Valdes MM.Intraosseous administration in emergencies. Lancet. 1977;1:1235.
  18. Vidal R, Kissoon N, Gayle M.Compartment syndrome following intraosseous infusion. Pediatrics. 1993;91:1201.
  19. Pediatric Forum.Emergency bone marrow infusions. Am J Dis Child. 1985;139:438.
  20. Fiser RT, Walker WM, Seibert JJ, et al. Tibial length following intraosseous infusion: a prospective, radiographic analysis. Pediatr Emerg Care.1997;13:186.
  21. Berg RA.Emergency infusion of catecholamines into bone marrow. Am J Dis Child. 1984;138:810.
  22. Neish SR, Macon MG, Moore JW, Graeber GM.Intraosseous infusion of hypertonic glucose and dopamine. Am J Dis Child.1988;142:878.
  23. Walsh-Kelly C, Berens R, Glaeser P, Losek J.Intraosseous infusion of phenytoin. Am J Emerg Med. 1986;4:523.
  24. Bilello JF, O'Hair KC, Kirby WC, Moore JW.Intraosseous infusion of dobutamine and isoproterenol. Am J Dis Child. 1991;145:165.
  25. Shoor PM, Berrynill RE, Benumof JL.Intraosseous infusion: pressure-flow relationship and pharmacokinetics. J Trauma.1979;19:772.
  26. Spivey WH.Comparison of intraosseous, central and peripheral routes of sodium bicarbonate administration during CPR in pigs. Ann Emerg Med. 1985;14:1135.
  27. Cambray EJ, Donaldson JS, Shore RM.Intraosseous contrast infusion: efficacy and associated findings. Pediatr Radiol.1997;27:892.