Intraosseous infusion

Intraosseous infusion

EZ IO devices

Intraosseous infusion (IO) is the process of injecting directly into the marrow of a bone to provide a non-collapsible entry point into the systemic venous system.[1] This technique is used to provide fluids and medication when intravenous access is not available or not feasible. A comparison of intravenous (IV), intramuscular (IM), and intraosseous (IO) routes of administration concluded that the intraosseous route is demonstrably superior to intramuscular and comparable to intravenous administration (in delivering paediatric anaesthetic drugs).[2]


This American Heart Association guideline cited two randomized controlled trials, one of 60 children[3] and one of electively cannulated hematology/oncology patients.[4] In addition, uncontrolled studies have been performed,[5][6] one of which reported 72% to 87% rates of successful insertion.[5]


NIO IO device
BIG IO devices
Axial CT with left humeral head EZ IO infusion of contrast.

The needle is injected through the bone's hard cortex and into the soft marrow interior which allows immediate access to the vascular system. An IO infusion can be used on adult or pediatric patients when traditional methods of vascular access are difficult or impossible. In most cases, the antero-medial aspect of the upper tibia is used as it lies just under the skin and can easily be palpated and located. The anterior aspect of the femur, the superior iliac crest and the head of the humerus are other sites that can be used.

This route of fluid and medication administration is an alternative one to the preferred intravascular route when the latter cannot be established in a timely manner. When intravascular access cannot be obtained intraosseous access is usually the next approach. It can be maintained for 24–72 hours, after which another route of access should be obtained.[7]

Although intravascular access is still the preferred method for medication delivery in the prehospital area, advances in IO access for adults has caused many systems to re-think their preferred secondary access route. In Massachusetts, for example, IO is now a preferred administration over endotracheal (ET) drug administration. In fact, the American Heart Association no longer recommends using the endotracheal tube for resuscitation drugs since the efficacy is unclear. Paramedics may perform intraosseous infusion in a cardiac arrest patient if no vein is clearly visible. The IO is becoming more and more common in emergency medical services (EMS) systems around the world.

Generally, any medication that can be introduced via IV can be introduced via IO. Because of this, adult IO systems (most of which use a mechanical or powered adjunct to place the catheter) have become more common across the United States in the prehospital setting. Intraosseous access has roughly the same absorption rate as IV access, and (unlike ET administration) allows for fluid resuscitation as well as high-volume drugs such as sodium bicarbonate to be administered in the setting of a cardiac arrest when IV access is unavailable. Endotracheal administration allows only specific drugs that have relatively low toxicity to lung tissue, and must be restricted to relatively low volumes to avoid drowning the patient.

Due to the rapid advance and adoption of superior intraosseous access technology, IO access has now become the preferred method of establishing vascular access for patients in whom traditional access is difficult or impossible. This includes patients experiencing cardiac arrest, major trauma, airway compromise, severe dehydration, and/or hypoperfusion (shock). IO is also an alternative route for patients who typically have poor peripheral vasculature or challenging vascular access such as diabetics, renal patients, burn victims, IV drug users, obese patients, dehydrated patients, the very young or elderly patients, and others. Many EMS services and hospitals are now using IO as their first line solution for vascular access in both adult and pediatric cardiac arrest victims, enabling administration of lifesaving drugs much earlier than previously possible with traditional peripheral IV placement.


The automatic intra-osseous devices allow quick and safe access to the patient's vascular system for fluid and drug administration. There are several FDA approved IO devices: The BIG Bone Injection Gun and The NIO New Intra Osseous device are automatic intra-osseous infusion device used by military and civilian healthcare systems; the battery-powered EZ-IO and hand-powered Fast1, Fast Combat and Fast Responder. Other devices include the Cook IO needle and the Jamshidi 15G.

There have been several studies comparing the EZ-IO and the BIG.[8][9][10] Another paper [11] compared the EZ-IO with the Cook IO needle.

Another study [12] compared the Jamshidi 15G, the BIG 15G, and the EZ-IO, finding that Success rates for first intraosseus iniecition attempt were higher for the BIG (91.59%) than EZ-IO (82.66%) or Jamshidi (47.66%). Mean procedure time was 2.0 ± 0.7 for the BIG vs 3.1 ± 0.9 minutes for EZ-IO vs 4.2 ± 1.0 minutes for Jamshidi.


  1. Tobias JD, Ross AK (2010). "Intraosseous infusions: a review for the anesthesiologist with a focus on pediatric use". Anesthesia & Analgesia. 110 (2): 391–401. doi:10.1213/ane.0b013e3181c03c7f. PMID 19897801.
  2. Moore GP, Pace SA, Busby W (1989). "Comparison of intraosseous, intramuscular, and intravenous administration of succinylcholine". PEDIATRIC EMERGENCY CARE. 5 (4): 209–210. doi:10.1097/00006565-198912000-00001. PMID 2602189.
  3. Banerjee S, Singhi SC, Singh S, Singh M (1994). "The intraosseous route is a suitable alternative to intravenous route for fluid resuscitation in severely dehydrated children". Indian pediatrics. 31 (12): 1511–20. PMID 7875811.
  4. Brickman KR, Krupp K, Rega P, Alexander J, Guinness M (1992). "Typing and screening of blood from intraosseous access". Annals of Emergency Medicine. 21 (4): 414–7. doi:10.1016/S0196-0644(05)82661-7. PMID 1554180.
  5. 1 2 Frascone RJ, Jensen JP, Kaye K, Salzman JG (2007). "Consecutive field trials using two different intraosseous devices". Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 11 (2): 164–71. doi:10.1080/10903120701205851. PMID 17454802.
  6. Davidoff J, Fowler R, Gordon D, et al. (2005). "Clinical evaluation of a novel intraosseous device for adults: prospective, 250-patient, multi-center trial". Journal of Emergency Medical Services. 30 (10): suppl 20–23. PMID 16382512.
  7. Vreede E, Bulatovic A, Rosseel P, Lassalle X (December 1, 2000). "Intraosseous Infusion" (PDF). Update in Anaesthesia. World Federation of Societies of Anaesthesiologists. 12: 38–40. ISSN 1353-4882. Retrieved 2010-07-03.
  8. Demir OF1, Aydin K, Akay H, Erbil B, Karcioglu O, Gulalp B. (July 2014). "Comparison of two intraosseous devices in adult patients in the emergency setting: a pilot study". Eur J Emerg Med. doi:10.1097/MEJ.0000000000000187. PMID 25075979.
  9. Leidel BA, Kirchhoff C, Braunstein V, Bogner V, Biberthaler P, Kanz KG (August 2010). "Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: A prospective, randomized study". Resuscitation. 81 (8): 994–9. doi:10.1016/j.resuscitation.2010.03.038. PMID 20434823.
  10. Shavit I, Hoffmann Y, Galbraith R, Waisman Y (September 2009). "Comparison of two mechanical intraosseous infusion devices: a pilot, randomized crossover trial". Resuscitation. 80 (9): 1029–33. doi:10.1016/j.resuscitation.2009.05.026. PMID 19586701.
  11. Brenner T, Bernhard M, Helm M, et al. (September 2008). "Comparison of two intraosseous infusion systems for adult emergency medical use". Resuscitation. 78 (3): 314–9. doi:10.1016/j.resuscitation.2008.04.004. PMID 18573590.
  12. Andrzej Kurowski, MD, Dariusz Timler, MD, Togay Evrin, MD, Łukasz Szarpak, MSc (2014). "Comparison of 3 different intraosseous access devices for adult during resuscitation. Randomized crossover manikin study". The American Journal of Emergency Madicine.
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