Intraosseous access

Last updated: July 12, 2023

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Summarytoggle arrow icon

Intraosseous (IO) access is an alternative route for administering medications, fluids, and blood products when peripheral or central venous access is not readily available. A large bore needle is passed through the bone cortex into the intramedullary space. Fluids and medications delivered through the IO needle are rapidly absorbed in the intramedullary sinusoids and delivered centrally. IO access is indicated whenever resuscitation is deleted by unsuccessful or difficult peripheral IV access. It is especially useful in cardiac arrest, shock, severe dehydration, and extensive burns. Multiple anatomic sites can be used for IO placement, and decision will depend on factors such as patient age and accessibility of the site. The proximal tibia is the most commonly used site. IO needle insertion is most commonly achieved using a semiautomatic insertion system. IO access should not be established in a limb with a fracture, infection, burn, or chronic pathologic condition. Complications are rare but include IO extravasation and infection.

Definitiontoggle arrow icon

A needle that transverses the bone cortex, terminating in the intramedullary space of a bone

Indicationstoggle arrow icon

  • Urgent need for patient resuscitation in the absence of other available or easily obtainable functioning venous access [2][3][4]
  • In cardiac arrest, obtain IO access if peripheral IV access is unsuccessful after 2–3 attempts OR takes > 90 seconds to establish. [3][5][6]

For patients in severe shock or cardiac arrest, IO access is faster to establish (typically < 1 minute) than central venous access or difficult peripheral IV access that requires multiple attempts. [7]

Contraindicationstoggle arrow icon

Avoid in patients with any of the following, unless absolutely necessary: [2][3][4]

We list the most important contraindications. The selection is not exhaustive.

Technical backgroundtoggle arrow icon

Access locations [2][3][4][7]

Needles and insertion devices [2][3][4]

Insertion devices are generally preferred over manual needle placement.

  • Semiautomatic insertion devices: EZ-IO® system, Bone Injection Gun®, NIO®
  • Manual needles: Jamshidi™ needle, Cook intraosseous infusion needle

Landmarks and positioningtoggle arrow icon

Equipment checklisttoggle arrow icon

Preparationtoggle arrow icon

  • Support the leg in a comfortable position.
  • Clean dirt and debris from the insertion site.
  • Identify insertion landmarks.
  • Choose the appropriate IO needle length. [2]
    • 15 mm (pink): patient weight 3–39 kg
    • 25 mm (blue): patient weight ≥ 40 kg
    • 45 mm (yellow): significant overlying tissue
  • Don PPE.
  • Prep skin to create a sterile field.
  • Apply a sterile drape.

Procedure/applicationtoggle arrow icon

IO insertion using semiautomatic system in adults [2][3][4]

Commonly used semiautomatic IO insertion systems include the EZ-IO® system.

  1. Administer single-point local anesthesia to the skin and periosteum in conscious patients.
  2. Attach an appropriately sized IO needle to the automated driver.
  3. Manually advance the needle (without using the trigger) at 90° through the skin until it touches bone.
  4. Activate the driver by pressing the trigger and push gently downward until a loss of resistance is felt.
  5. Grasp the needle and remove the driver.
  6. Remove the stylet with a counterclockwise motion.
  7. Attach the needle stabilizing device.
  8. If applicable, attach the associated extension set and aspirate.
  9. Slowly administer 2% lidocaine if the patient is in pain. [2]
  10. Flush the needle with 5–10 mL of saline.
  11. Apply a sterile dressing.

IO removal

Remove the IO needle within 24 hours of insertion to minimize the risk of complications.

  1. Attach a Luer-Lok syringe to the needle.
  2. Pull it out straight while rotating it clockwise.

Do not rock the needle during removal.

Pitfalls and troubleshootingtoggle arrow icon

  • Resistance to fluid flow [2][4][7][8]
    • Penetration into the opposite cortex (most common mistake) : Withdraw the needle 1–2 mm and recheck fluid flow.
    • Incomplete penetration of the cortex : Replace the stylet and advance the needle until bone marrow can be aspirated.
    • Obstruction of the needle : Flush IO access frequently and after every medication administration with 3–5 mL of saline. [2]
  • IO extravasation or IO infiltration [2][4][7][8]
    • Ensure the IO needle is in the correct position.
    • Examine for cortical injury, e.g., fracture, previous IO access attempt, widening of IO access site.
  • Pain [2][4][7][8]

Easy bone marrow aspiration, minimal resistance to a fluid flush, stability of the needle in the bone, and no evidence of IO extravasation suggest correct IO access placement. [4]

Postprocedure checklisttoggle arrow icon

Complicationstoggle arrow icon

Complications are uncommon, especially if the needle is removed within 24 hours of insertion. [2][4][7]

We list the most important complications. The selection is not exhaustive.

Referencestoggle arrow icon

  1. $Contributor Disclosures - Intraosseous access. All of the relevant financial relationships listed for the following individuals have been mitigated: Esther Welzel (illustrator, is an independent contractor for Fluentis Schweiz); Luisa Voßbeck (medical editor, was previously employed by GÖK Consulting GmbH). None of the other individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
  2. Roberts JR. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier ; 2018
  3. Reichman EF. Emergency Medicine Procedures, Second Edition. McGraw-Hill Education / Medical ; 2013
  4. Petitpas F, Guenezan J, Vendeuvre T, Scepi M, Oriot D, Mimoz O. Use of intra-osseous access in adults: a systematic review. Critical Care. 2016; 20 (1).doi: 10.1186/s13054-016-1277-6 . | Open in Read by QxMD
  5. Paxton JH. Intraosseous vascular access: A review. Trauma. 2012; 14 (3): p.195-232.doi: 10.1177/1460408611430175 . | Open in Read by QxMD
  6. Baadh AS, Singh A, Choi A, Baadh PK, Katz DS, Harcke HT. Intraosseous Vascular Access in Radiology: Review of Clinical Status.. AJR Am J Roentgenol. 2016; 207 (2): p.241-7.doi: 10.2214/AJR.15.15784 . | Open in Read by QxMD
  7. Lucas JK, Vera AE. Intraosseous Access. Springer International Publishing ; 2022: p. 629-633
  8. Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020; 142 (16_suppl_2).doi: 10.1161/cir.0000000000000916 . | Open in Read by QxMD

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