Intra Osseous (IO) access

Rationale

• Venous Access may be difficult in children, sometimes more so in the critically ill child.
• It is indicated in a child following two failed attempts at cannulation (90 seconds) when IMMEDIATE access is required.

Equipment

Intraosseous needles:

• IO needle with handle attached
• Sterile towels
• Sterile gloves
• Betadine or chlorhexidine
• 5ml and 10 ml syringe
• Normal saline ampoule

Surface markings:

• Adhesive tape

Placement

The preferred site is the anterior tuberosity, 2-3 cm below the tibial tuberosity (the anteromedial flat part of the tibia).

If the Tibia is fractured, an alternate site is the inferior part of the femur, 3 cm above the external condyle.

Procedure

• Surgically prep the area.
• If patient is conscious, use local anaesthetic.
• Insert at 90 degrees to the skin, with a screwing motion into the anteromedial surface of the tibia. There is usually a sense 'loss of resistance' as the marrow cavity is penetrated.

Insertion of needle:

• Attach the 5 ml syringe; aspirate and flush to confirm correct positioning.
• Attach the N/S-filled syringe and push in the fluid boluses.
• The IO should be replaced with IV cannulation once resuscitation has taken place.

Venous cutdown

Rationale

Venous cutdown should be performed only as a last resort for venous access.

The advantage is that with IV cutdown, a large-bore cannula can be inserted under direct vision. Usually using the long saphenous the procedure may be carried out away from and therefore not interfering with the on-going resuscitation

Equipment required

• IV cutdown pack
• Sterile gown and gloves
• Sterile towels x 2
• Chorhexadine skin prep
• 5ml syringe
• 25g needle
• Lignocaine 1% 5ml ampoule
• N/Saline 10ml ampoule
• Syringe for taking blood
• 3/0 nylon suture and needle
• IVC Large bore
• Scalpel
• 3- way tap with 10cm extension
• Tegaderm
• I.V fluids and tubing

Placement

The distal saphenous vein in the ankle is the most common site for a venous cutdown. The saphenous vein is just anterior to the medial malleolus.

Procedure

• Surgically prepare the area.
• Infiltrate the skin and subcutaneous tissues with local anaesthetic.
• Make incision of 1-2 cm through the skin over the vein. Bluntly dissect down to the vein (using mosquito forceps to open up the tissues and expose the vein).
• If you can't see the vein, gently run the point of the forceps over the tibia to locate it.
• Pass two silk sutures under the vein, then apply traction on the distal of the two sutures to better expose the vein.
• Incise the vein length-ways and pass a large bore cannula into the lumen.
• Tie the proximal suture around the cannula in the vein - firmly, but not so tight as to occlude the lumen of the cannula.
• Aseptically connect the IV giving set.
• Suture the incision site closed and cover with a sterile dressing.