critical care medicine
How To Do Intraosseous Cannulation, Manually and With a Power Drill
Step by Step Description of Intraosseous Cannulation
Pre-flush all IV lines and connecting tubes with normal saline. Put on gloves, face mask, face shield, and other personal protective equipment as needed. Prepare a syringe with 5 to 10 mL sterile saline in it. For insertion-site anesthesia, draw 3 to 5 mL of 1%lidocaineinto a syringe and attach the 25-gauge needle. For medullary space anesthesia, draw 3 to 5 mL of 2 % preservative-free IVlidocaineinto a syringe. Prepare the manual needle or the power drill (eg, screw the stylet securely into the needle and attach the assembly to the drill, and set any insertion depth limiters appropriately to the patient’s age and size). Swab the area of skin around the cannulation site with antiseptic solution, using outwardly expanding concentric circles. For children, include both the proximal tibia and distal femur in the swabbed area. Allow the antiseptic solution to dry for at least 1 minute. From this point forward, nonsterile items are forbidden from the anticipated needle-insertion site. For a conscious patient: Inject 3 to 5 mL of 1%lidocaineinto the skin and soft tissues along the anticipated needle-insertion path, including the periosteum. The physician’s fingers and thumb are wrapped around the proximal tibia to stabilize it; the hand should not be placed directly behind the insertion site (to avoid self-puncture). Instead, a towel may be placed behind the knee to support it. The physician holds the needle firmly in the palm of the other hand, directing the point slightly away from the joint space and growth plate. The needle is inserted with moderate pressure and a rotary motion, which is stopped as soon as a pop indicates penetration of the cortex. Some needles have a plastic sleeve, which can be adjusted to prevent them from being pushed too deeply into or through the bone. Palpate the insertion site with your nondominant hand. Stabilize the insertion site, by wrapping your nondominant hand around the extremity near the site. Do not place your hand directly behind the insertion site (to avoid self-puncture). Firmly hold the drill or the manual needle in your dominant hand. Position the needle tip at the point of insertion, perpendicular to the long axis of the bone. Point the needle slightly (10 to 15 degrees) away from the joint space and growth plate. Manual insertion Stabilize the needle shaft at the skin surface with an index finger, to help you stop the needle's advance once the cortex is penetrated. Some needles have an adjustable plastic sleeve for this purpose. Advance the needle with moderate pressure and a to-and-fro rotary, coring motion. Advance along a straight path, so that the hole will be as narrow as possible (to prevent fluid extravasation). Stop advancing the needle when you feel the pop (sudden loss of resistance) that indicates penetration through the cortex and into the medullary space, to prevent the needle from being pushed too deeply into, or through, the bone. Insertion using a power drill Penetrate the skin: Squeeze the trigger, and apply gentle pressure to penetrate the skin. Advance the needle: Continue to squeeze the trigger while applying steady, downward pressure against the resistance of the cortical bone. Immediately release the trigger and stop advancing the needle when you feel the sudden loss of resistance that indicates entry into the medullary space. Detach the drill from the needle, keeping the needle in place. Seeing the needle remaining upright without support is the first sign of proper needle placement. Remove the cap and the stylet, attach pre-flushed extension tubing, and aspirate. Free return of blood (marrow) confirms correct intramedullary placement. If no marrow is aspirated,push 5 to 10 mL of normal saline through the needle. If you feel resistance to the push and see or palpate local swelling (extravasation),remove the needle and cannulate another bone. First, instill intramedullary anesthesia (for a conscious patient): In adults, slowly (over 2 to 3 minutes) infuse 2 mL of 2 % preservative-free IVlidocaine(40 mg), may repeat 20-mg doses until pain stops (maximum total dose 100 mg [5 mL]). For children, slowly infuse 0.5 mg/kg (0.025 mL/kg) for a maximum of 20 mg (1 mL). Wait 1 minute, and then flush with 5 to 10 mL of normal saline. Begin the infusion. (IV fluid flowing freely without extravasating into surrounding tissues is another sign of correct needle placement.) Wrap sterile gauze about the needle entry site and securely tape in place; commercial intraosseous kits may contain specialized dressings. If needed, immobilize the extremity to further protect the site. 