366 Section IX ■ Miscellaneous Procedures

c. If extravasation occurs, withdraw needle and select a

different bone.

18. When needle position is confirmed

a. Attach syringe and infuse medications or fluid

directly into the needle or via an IV extension set

with clamp. Clear medications with saline flush.

b. For continuous infusion, attach a standard IV infusion

set with an infusion pump to the intraosseous needle

and administer at the same rate as for IV infusion (2).

19. Secure intraosseous needle and maintain a clean infusion site while the needle is in place.

a. Tape the flanges of the needle to the skin to prevent

dislodgement. If a needle safety latch is provided,

attach the latch and then apply tape.

b. If desired, cover the exposed end of the needle with

a disposable cup, taping the cover down. Cutting off

the bottom of the cup will aid in visualization of the

site for monitoring.

20. Secure IV tubing with tape to the leg.

21. Secure the leg to the armboard.

22. Obtain radiograph to confirm position of needle and to

rule out fracture.

23. Monitor frequently for fluid extravasation.

24. Discontinue intraosseous infusion as soon as alternative

IV access is achieved.

In an infant with hypotension/hypovolemia, infusion via the interosseous route can restore peripheral

perfusion to a point at which venous access is possible

in well under 30 minutes.

a. Remove needle gently, with slight rotation motion if

needed.

b. Apply a sterile dressing over the puncture site.

c. Apply pressure to the dressing for 5 minutes.

Distal Tibia (2,10,11) (Fig. 50.5)

1. Position patient supine.

2. Prepare site and needle as for proximal tibia.

3. Insert needle in the medial surface of the distal tibia

just proximal to the medial malleolus.

4. Direct needle cephalad away from the joint space.

5. Proceed as for proximal tibia.

Distal Femur (1) (Fig. 50.2)

1. Position patient supine.

2. Place sand bag or towel roll behind knee.

3. Prepare site and needle as for proximal tibia.

4. Insert needle 1 to 3 cm above the external condyles in

the anterior midline.

5. Direct needle cephalad at an angle of 10 to 15 degrees.

6. Proceed as for proximal tibia.

F. Complications (1,4,16,17)

1. Fracture of bone (18)

2. Complete penetration of bone (19)

Fig. 50.5. Intraosseous infusion into the distal tibia. (Reproduced

with permission from Spivey WH. Intraosseous infusions. J Pediatr.

1987;111:639.)

3. Osteomyelitis (16,17)

4. Periostitis (17)

5. Subcutaneous abscess

6. Cellulitis

7. Sepsis

8. Extravasation of fluid from the puncture site

9. Subperiosteal or subcutaneous infiltration or

hematoma