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1123.e2 Intraosseous Catheter Placement

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Intraosseous Catheter Placement Available
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Additionally for manual insertion:
Difficulty level: ♦♦
• Spinal needle or bone marrow needle: common unless it is immediately removed
and replaced with a second needle. Locating
Overview and Goal typically 18-22 gauge, 1 2 or 2 2 inches the original hole is challenging, and there
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Manual or automated insertion of catheters (4-6 cm) long may be leakage of fluid at the bone insertion
into the bone marrow cavity for administer- • T-port–type injection cap with side connector site. A spinal needle or bone marrow needle
ing parenteral fluids, drugs, blood, or virtu- • Bandage material: roll gauze, cast padding, with stylet is therefore preferred.
ally any other agent that is routinely given stretch-and-release bandage (e.g., Vetrap), Automated insertion:
intravenously white medical tape • Leakage around the catheter (uncommon,
• Suture scissors and bandage scissors usually not clinically significant; monitor for
Indications • ± Splint material (e.g., wooden tongue limb swelling during fluid administration)
• Resuscitation of hemodynamically unstable depressor in pediatric patients) to protect • Pain during placement of the catheter
patients (most common indication) the spinal needle after placement (common; manageable with 2% lidocaine
• Cardiopulmonary arrest: fluid and drug Additionally for automated insertion: block to level of periosteum)
administration • EZ-IO automated driver (or equivalent • Pain with infusion of fluids (common when
• Plasma or blood transfusion in an animal automated device with appropriate IO fluids administered at rapid rates; manageable
that has poor peripheral or jugular venous catheters) with 2% lidocaine infusion through the
access • Appropriate size EZ-IO catheter (15-gauge catheter before fluid administration)
• Administration of drugs when intravenous catheter: 1.5-cm, 2.5-cm, and 4.5-cm lengths • Infection (rare)
(IV) access is not available (used in place of available) • Fracture (rare)
an emergency venous cut-down) • T-port–type injection cap with side connector • Compartment syndrome if catheter tip
• Manual technique for kittens or puppies or EZ-connect low-profile extension set traverses the distal cortex (rare; monitor for
(bone is soft and easily traversed) limb swelling during fluid administration)
• Automated technique for cats and dogs with Anticipated Time
mature bone that is more difficult to traverse • About 20 minutes for manual insertion Procedure
with manual techniques • About 5 minutes for automated (less if clip Manual femoral approach
and sterile scrub is not performed; actual • Sedation/general anesthesia is administered
Contraindications EZ-IO catheter placement takes < 10 if deemed necessary based on mentation,
• Osteopenia (nutritional or metabolic bone seconds) extent of illness, and vital signs.
disease), cancer, or fracture affecting the • With the animal in lateral recumbency, the
target bone Preparation: Important nondependent leg is used.
• Infection of the overlying soft tissues Checkpoints • Palpate the hip; the greater trochanter of
• Previous surgery involving implants in the • Review anatomic landmarks. the femur is the outer/lateral landmark, and
target bone • The humerus is preferred to the tibia in cases the trochanteric fossa medial to the greater
• Prior placement of an intraosseous (IO) of cardiopulmonary resuscitation (more rapid trochanter is the target.
catheter within 48 hours in the target delivery of drugs to the heart). • The overlying skin is clipped of hair and
bone • Consider alternatives (e.g., IV catheter, aseptically prepped.
venous cutdown). • In the absence of sedation or general anes-
Equipment, Anesthesia • In healthy adult dogs, IO samples aspirated thesia, local anesthetic is infiltrated into the
• Sedation or general anesthesia is necessary through an EZ-IO catheter act as a surrogate trochanteric fossa.
for animals that are otherwise well. However, to peripheral IV blood for glucose, lactate, • Using a scalpel blade, a 2-mm stab incision
IO catheters are often placed in severely pH, and most electrolytes. Hematocrit, is made in the skin overlying the trochanteric
debilitated animals; local anesthesia with packed cell volume, and potassium cannot fossa.
2% lidocaine (typical kitten/puppy dose: be used interchangeably with IV blood • The femur is rotated internally, adducted, and
0.25 mL) is sufficient for these animals, samples. held in this position during needle placement
provided all tissue layers are infiltrated to reduce the risk of sciatic nerve injury.
(subcutis, muscle, periosteum). Possible Complications and ○ The sciatic nerve courses medial to the
• IO injection of fluids is associated with pain. Common Errors to Avoid trochanteric fossa, dorsal to the acetabu-
Slow administration of 1-2 mg/kg (dogs) or Manual insertion: lum. Entering the trochanteric fossa from
0.25 mg/kg (cats, administer slowly) of 2% • Damage to nerves (especially sciatic) or its lateral-most aspect minimizes the risk
lidocaine through the catheter after place- vessels. Locating landmarks and using proper of sciatic nerve damage.
ment is advised. For long-term use, this may technique minimizes this risk. • Insert the spinal needle through the stab
be repeated as needed while avoiding central • Spinal needle kinking, causing obstruction, is incision and onto the greater trochanter
nervous system toxicosis. common. Minimized by using shorter needles (lateral to target). Slowly move the needle
Manual and automated insertion: that are not overly thin (it is rare to use medially (in a walking fashion) until it enters
• Clippers for hair anything smaller than a 22-gauge needle even the trochanteric fossa.
• Isopropyl alcohol, surgical scrub supplies, in the smallest animals) and by bandaging • Once in the trochanteric fossa, advance the
and sterile gauze squares the proximal/protruding part of the needle needle parallel to the long axis of the bone.
• Sterile gloves to reduce the lateral forces applied to it when Grasp the hub of the needle firmly to allow
• A #11 or #15 scalpel blade and handle the animal bumps against the cage wall, lies a burrowing, clockwise-counterclockwise
• Tissue glue down, or rolls over. rotating motion to facilitate advancement.
• Sterile heparinized saline flushes • Using a regular 18-gauge needle (hypo- A mild loss of resistance is usually felt when
• A 2% lidocaine flush (1-2 mg/kg for dogs, dermic/injection-type) has been described, the needle reaches the marrow cavity. NOTE:
0.25 mg/kg for cats) but needle occlusion with cortical bone is It is important not to advance the needle

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