Intraosseous Access for Administration of Medications in Neonates

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Evidence review

An electronic search of Medline (Ovid), Embase, and the Cochrane Database of Systematic Reviews was undertaken. Bibliographies of journal and review articles were hand-searched for additional references. Search criteria included neonatal human studies. The body of literature specifically focused on neonates yielded 56 articles pertaining to intraosseous access in neonates and young infants. Four case reports and a single series of 27 preterm and term neonates showed that intraosseous access

History

Infusions of blood and other fluids into the circulation by way of the bone marrow was first described in the 1940s as an alternative to infusion through the superior sagittal sinus in newborns and when intravenous access was impossible in older children and adults (eg, widespread mutilations, burns, edema, poorly developed or obliterated veins, states of shock) [6], [7]. Tocantins et al [8] reported the technique, results, and success during traumatic shock and other forms of circulatory

Technique

The technique to establish an intraosseous route for vascular access in young children has been reviewed by several authors [11], [12], [13], [14], [15], [16], [17], [18]. The proximal tibia is the most commonly used site for intraosseous access in infants and children. The distal femur, medial or lateral malleoli, and iliac crests are alternative locations. The proximal tibial site is approximately 1 cm below the tibial tuberosity and medially located on the tibial plateau. The distal femur

Physiology

The long bones are composed of a dense outer layer of bone that surrounds a spongy medullary cavity (Fig. 1). The medullary cavity contains bone marrow, fat tissue, blood vessels, and nerves. After 5 years of age, the red marrow is replaced by the less vascular yellow marrow in the long bones of children, making access more difficult. The thin mantle of bone in the sternum of young infants and children and ease of needle insertion penetrating through the back of the sternum argue against the

Clinical indications

Intravascular access may be required during resuscitation of some neonates and young children. The key to resuscitation in neonates is adequate ventilation. Respiratory insufficiency accounts for most cardiopulmonary arrests in this age group [19], [20]. Administration of chest compressions and medications during cardiopulmonary resuscitations of neonates in the delivery room occurred in only 0.12% of 30,839 newborns delivered during a 2-year period [20]. Nevertheless, clinicians caring for

Complications

Intraosseous medication and fluid administration is invasive, and complications may occur. The risk of complications is low, however. Osteomyelitis occurs in less than 1% of patients and has been associated with hypertonic fluid or medication infusion [9], [11], [12], [18]. Subperiosteal or soft tissue extravasation, compartment syndrome, air or fat embolism, abnormal bone growth, medication or transfusion reactions, local tissue reactions, mediastinitis, and abscess formation also may

Contraindications

Bone disease is a contraindication for placement of an intraosseous needle or infusion [11], [12], [18]. This is particularly true for infants with osteogenesis imperfecta, osteopetrosis, or other illnesses associated with a propensity to fracture. A previously used site of an intraosseous needle is a relative contraindication for a short time (1–2 days) because fluid may leak through unhealed needle tracts. Overlying cellulitis, burn, and other infection are additional contraindications.

Gaps in knowledge

Evidence to support use of the intraosseous route for vascular access in neonates is limited to case reports and biologic plausibility. Randomized or historical controlled trials in neonates are unlikely because venous access is nearly always obtainable, and the incidence of resuscitations requiring intravascular access is low. Because clinical reports are limited to descriptions of successful cases, no information is available on success rates, complication rates, or best needle types in the

Summary

Intraosseous administration of resuscitation medications and fluids in preterm and term neonates is an alternative when intravascular access is not possible with intravenous catheters or needles. Intraosseous access is rarely needed in neonates because of the availability of clinicians with expert technical skills for placement of intravenous catheters in neonatal ICUs, the presence of the umbilical vein during the first days after birth when most resuscitations occur, and the predominance of

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References (25)

  • J. Ramet et al.

    Successful use of an intraosseous infusion in an 800 grams preterm infant

    Eur J Emerg Med

    (1998)
  • L.M. Tocantins et al.

    Infusion of blood and other fluids into the circulation via the bone marrow

    Proc Soc Exp Biol Med

    (1940)
  • Cited by (0)

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