Intraosseous Fluid Infusion
(Alternative methods of fluid therapy when I.V. access is not available)
Common Bed Side Procedure No. 2
Section Editor: Prof. T.K. Partha Sarathy

When a few attempts at I.V. cannulation in a child less than 6 years old are unsuccessful a viable alternative method is to utilize tibial puncture and give the fluid intraosseously.

Preconditions for the procedure:
1. Not indicated above the age of 6
2. When I.V. access is not possible and the situation is an emergency
3. Aseptic precautions should be followed very carefully (Serile technique)
4. To be utilized only for a short period until venous access is made possible
5. Use only if the limb is uninjured.

Requirements:
a. Betadine solution for scrub
b. Sterile drapes
c. Sterile gloves
d. 10 cc syringe half filled with Normal Saline
e. A large caliber bone marrow aspiration needle or a 18 gauge spinal needle with stylet
g. ½% Xylocaine

Procedure:
Child placed in supine position, with adequate restraints as necessary the selected lower extremity is positioned on a pillow with the knee flexed (about 30o), utilizing padding under the knee and the heel of the foot resting on the surface comfortably.
Wear sterile gloves. Prepare the upper antero-medial surface of the tibia with betadine solution and sterile drapes are applied.

The tibial tubercle is identified at least 1” below (2 to 3 cm) the tubercle of the tibia. The puncture site is chosen and if necessary infiltrate with ½% Novocaine using the bone marrow needle or a 18 gauge spinal needle. The cutaneous puncture is made at a 900 angle at the chosen site and by a gentle twisting and boring motion the needle is advanced through the bone cortex into the bone marrow pointing towards the foot and staying away from the epiphyseal plate. The sudden give of the needle into the bone marrow will indicate good position. At this point the stylet of the needle is removed and the saline filled syringe is attached to the needle and some bone marrow is aspirated. Most often it is easy to aspirate a little bone marrow and the same saline could be utilized to flush and clear the needle of any bone marrow or clots. Once a free flow is ascertained with the syringe the I.V. fluid kept ready with the tube is connected to the needle.
Antibiotic ointment is applied around the needle site and appropriate dressings given.
If there is any subcutaneous swelling it indicates extra vasation of fluid and the bone marrow needle has to be repositioned.
(Caution must be exercised that this procedure is utilized only in emergency situations and only for a brief period to tide over the situation in children below 6)

Complications of procedure : infections leading to sepsis, cellulitis and even osteomyelitis.

	Prevention: • Absolute aseptic precautions, limited period of utilization, sterile technique, extra vasation of fluid into periosteum and subcutaneous tissue.
• Careful placement and attention to details, Hematoma; usually small and self limited inadvertent injury to a blood vessel in this area is very unlikely. • Placement properly in the proximal tibia, Epiphyseal plate injury. This has to be avoided by staying at least 2 cm away from the tibial tubercle and the needle pointing towards the foot and not proximally.

Note: Used sparingly and when necessary without hesitation this is a valuable method of fluid resuscitation in a child suffering from shock, particularly following a major injury.