Chapter 32

It can be difficult to obtain venous access in infants and children. This chapter presents vascular access techniques, including intraosseous (IO), central venous, and umbilical venous access in the newborn.

The principle of IO access is that fluids and medications administered into noncollapsible bone sinuses rapidly enter the central circulation. Although the IO approach may be used in any age patient, it is particularly amenable to children as a result of their high percentage of red bone marrow and relatively thin bony cortex.1,2

Access to the bone marrow is indicated when there is an emergency need for vascular access, and other central or peripheral sites are not easily cannulated. A case series of pediatric resuscitations demonstrated the mean time to manual IO placement was 4.7 minutes with a success rate of 83% compared with an average time to intravascular access of 7.9 minutes.3 More recent studies using newer devices have demonstrated insertion times of only seconds with success rates of 94%.4 Various insertion devices include simple hand-twist needles, hand-held drills, and spring-loaded devices.

There are relatively few contraindications to IO placement (Table 32-1), and the reported rate of serious complications from IO insertion is about 1%.5 By comparison, central venous catheters have complication rates of at least 3.4%.6

Table 32-1 Contraindications to IO Placement

Paralytics, anticonvulsants, analgesics, benzodiazepines, and vasopressors such as epinephrine have comparable infusion IO and IV infusion rates (Table 32-2). Blood and blood products can be given by the IO route.7,8 Though pharmacokinetics may differ between IV and IO routes of administration, any medication or fluid that can be given through an IV can be administered through an IO. Substances that are toxic to tissues, such as hypertonic solutions or caustics (e.g., calcium), can cause skin necrosis if they extravasate into the soft tissues whether from a misplaced peripheral IV or a misplaced IO needle, and proper positioning of the catheter or needle should always be checked before administration of these medications.

Table 32-2 Medications That Are Comparable with IO or IV Infusion

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