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What is intraosseous catheterization?
placement of a cannula into the medullary cavity of a bone in order to administer fluids
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Why would we do intraosseous catheterization?
provides rapid access to the central circulatory system through the capillary rich bone marrow
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What can we give patients through an intraosseous catheterization?
- blood
- colloids
- crystalloids
- drugs
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What is the abbreviation for intraosseous catheterization?
IO
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Do drugs given IO show a clinical effect as well and as fast as drugs administered by the peripheral IV route?
yes
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Why is fluid rate limited when administering fluids IO?
due to the inelastic nature of bone
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What is the fluid rate for IO?
11 ml/minute
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If we need to administer fluids rapidly IO for shock treatment, what should we do?
place more than 1 line
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If more than one IO catheter must be placed, it must be placed in a _____.
different bone
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What kind of fluid administration can cause lameness when giving fluids IO?
hypertonic saline
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What are the indications for placing an IO catheter?
- unable to place a standard IV catheter
- technique of choice for birds, neonates, exotics
- frequently an emergency procedure
- alternate method of access to the circulatory system for rapid delivery of large volumes of fluid
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What are some reasons why we would not be able to place a standard IV catheter?
- shock
- size of patient - neonatal puppies and kittens
- species - birds have fragile veins
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What are some reasons why we would not want to place an IO catheter?
- skeletal abnormalities
- local infections or fractures or skin broekn at insertion site (can cause osteomyelitis)
- consider whether you are doing more harm than good or more good than harm (it might be nice to stay alive long enough to get osteomyelitis)
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What kind of equipment do we need for an IO catherization?
same as for an IV catheter but using a different type of catheter
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Describe an IO catheter.
rigid cannula that can penetrate cortical bone and should ideally contain a stylet to prevent clogging by bone
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What kind of needles can we use for an IO catheter?
standard hypodermic needle, a spindle needle, or a bone marrow needle
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Who would we use a 20 - 22g 1 - 1.5 inch spinal needle for?
- cats, small exotics, birds, young dogs
- stylet prevents clogging with bone
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Who would we use a 18 - 25g hypodermic needle for?
- neonates because they have softer spongy bone
- we can use it in adults dogs and cats, but a small IM pin can be used to pre-drill the hole and a hypodermic needle slightly larger than the hole can be inserted
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What do we do if the needle becomes clogged with cortical bone?
remove it and replace it with a new, slightly larger needle placed into the same hole
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Who would we use a bone marrow needle for?
- adult dogs and cats
- hypodermic and spinal needles are likely to bend or break
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How do we select place for the IO catheter?
- select according to ease of access and patient condition
- do not go through infected tissue or into traumatized bone
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What are some specific sites we can use?
- femur
- tibia
- tibiotarsus
- hip
- ulna
- humerus (greater tubercle of humerus)
- sternum
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When would it be good to use the femur?
good for active animals because it does not limit movement
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Where in the femur would we insert the catheter?
trochanteric fossa of the femur
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When would it be good to use the tibia?
- more accessibe in obese animals
- easier to stabilize in case of seizures
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Where on the tibia can we insert the catheter?
- flat medial surface of proximal tibia
- tibial tuberosity
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What is the tibiotarsus?
avian drumstick
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When would it be good to use the ilium of the hip?
- insert in the wing of the ilium
- good for animals that cannot be moved from sternal recumbency or who must stand in order to breathe easily (congestive heart failure)
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Other than the ilium where else on the hip can we insert an IO catheter?
ischium
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Where on the ulna in birds can we insert an IO catheter?
distal end of ulna
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What kind of bones do we need to avoid using when inserting an IO catheter in birds?
pneumatic bones
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How do we prepare the site for an IO catheter? Do we need to use aseptic technique?
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What is infiltrate and why do we do this?
- local anesthetic at insertion site
- because it is painful
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How do we infiltrate?
- SQ at insertion site then down onto the periosteum of bone
- the needle should be introduced down the medial side of the greater trochanter and "walked" down the bone into the fossa, injecting small amounts of local anesthetic as the needle is advanced
- this avoids the sciatic nerve
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What kind of local anesthetic do we use for infiltration?
1% lidocaine or 0.5% lidocaine in neonates, cats, or geriatrics
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How do we make the incision and what do we use?
- make a small incision over insertion site
- with scalpel blade or 20 gauge needle tip
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Why is positioning important when placing an IO catheter in the trochanteric fossa?
to avoid damaging the sciatic nerve
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How should we position when placing a IO catheter in the trochanteric fossa?
- hip joint should be neutral to slightly extened with the femur externally rotated
- "walk" down the medial side of the greater trochanter into the trochanteric fossa
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What is the location for placing an IO catheter in the medial tibia and how do we place it there?
- flat medial surface of proximal tibia
- approximately 1 - 2 cm distal to tibial tuberosity
- direct needle distally away from proximal growth plate
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Describe how we place an IO catheter once we have the patient positioned, preped, infiltrated, and the incision in the skin has been cut.
- apply pressure to cannaula along with firm rotation in quarter turns
- this creates a small depression in the bone, which "seats" the needle
- once the needle is seated, continue same rotation pattern with increased pressure to drive through the cortex
- as the needle passes through the cortex, resistance will decrease
- check placement of the needle
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What are the different ways to check the placement of the needle?
- flick the needle with a finger: if needle is well placed, it should not wobble when flicked
- move the limb: the needle should move with the limb without becoming dislodged
- attach a 10ml syringe to the hub of needle and aspirate: should get bone marrow (fat, bone spicules, blood)
- flush with heparinized saline: if it does not flush easily then rotate the needle some or withdraw a mm or two, if fluid still won't flow freely then bone may be lodged in needle and use a wire stylet to clear or forcefully inject
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How can we secure the needle?
suturing
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After we have secured the needle what should we do?
- attach IV extension set to minimize manipulation of cannula later
- apply antibiotic ointment to insertion site
- bandage to protect cannula from bending or breaking
- use and maintain with a regular IV catheter
- flush QID if not used for continuous infusion
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How do we check for leakage and what should we do if there is any?
- watch for fluid accumulation SQ
- if more than one hole was placed in the bone, the leakage is likely
- if a bone has a leaky hold, do not reuse for 12 - 24 hours - use another bone
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Can the place where the IO catheter is placed get infected?
yes
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What are some rare complications a patient can have with an IO catheter?
- fat or marrow emboli to lungs
- damage to growth plate
- bone fractures
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How long can an IO cannula be left in?
up to 72 hours
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