Common insertion sites

• Proximal tibia: commonly used in adults and children
• Proximal humerus: adult option with high flow rates
• Distal tibia: useful in children and adults
• Sternum: only with an approved sternal device, usually adults

Stepwise technique

1. Indication and preparation
   • Use when immediate vascular access is needed and IV access is delayed or unsuccessful.
   • Use gloves, antiseptic skin preparation, correct needle length, extension tubing, saline flush, and securement.
   • If the patient is conscious, give local anesthetic where feasible.
2. Identify landmarks
   • For the proximal tibia in adults: locate the tibial tuberosity, then select the flat medial surface about 2 cm medial and 1-2 cm below it.
   • In small children: use the flat anteromedial proximal tibia, avoiding the growth plate.
3. Insert needle
   • Clean the skin and allow antiseptic to dry.
   • Stabilize the limb.
   • Insert the IO needle at 90 degrees to the bone surface.
   • Advance using the manual or powered device until there is a distinct loss of resistance as the needle enters the medullary cavity.
   • Stop advancing, remove the stylet, and attach extension tubing.
4. Confirm placement
   • The needle should stand firmly without support.
   • Attempt marrow aspiration, but failure to aspirate does not by itself mean failure.
   • Flush with saline while observing for swelling, leakage, or resistance.
   • Check that fluid infuses freely and there is no soft-tissue infiltration. The NCBI procedural review describes confirmation by stability and unobstructed flush.
5. Use and secure
   • Secure the line and label it clearly as IO.
   • Give resuscitation drugs, fluids, blood products, and laboratory samples as indicated. Pressure infusion is often required for adequate flow.
   • In an awake patient, medullary flushing and infusion can be very painful. Give appropriate analgesia according to local protocol.
6. Remove promptly
   • Establish conventional IV or central access as soon as practical.
   • IO access is temporary, generally removed within 24 hours.
   • After removal, apply pressure and dress the site.

Complications

• Extravasation and compartment syndrome
• Fracture, especially in small children or in abnormal bone
• Osteomyelitis or cellulitis
• Growth-plate injury in children if landmarks are incorrect
• Rare fat embolism