University of Colorado Hospital Policy and Procedure

Intraosseous Lines

Related Policies and Procedures:
Administration of Blood Components
Peripheral Venous Lines
Intravenous (IV) Care and Maintenance

Approved by: Professional Practice Policy and Procedure Committee
Effective: !"#
$evised: %%"&'(

Description: )his policy addresses the insertion* care* and discontinuation of Intraosseous
(I+) catheters, $efer to Vascular Access -e.site for pictures and descriptions of the different I+
.rands,

Accountability:
Physician may insert I+ (Intraosseous) access devices after completin/ trainin/,
$e/istered nurse ($0) may do the follo1in/: Insert I+ devices (after completin/ trainin/)(if
competency trained to do so)* prime"chan/e I+ tu.in/* perform simple dressin/ chan/es
includin/ I+ site care* access I+ lines and dra1 samples for la.oratory testin/* administer fluids
and medication via I+ lines and discontinue a peripheral I+ catheter after completin/
demonstratin/ competency,trainin/,
Emer/ency )echnicians 2 Paramedic (EM)3P) and * Emer/ency Medical )echnicians (EM)
.asic and 1ith IV certification) may): insert I+ access devices after .ein/ competency trained to
do so prime"chan/e I+ tu.in/* perform simple dressin/ chan/es includin/ I+ site care after
demonstratin/ competency and discontinue a peripheral I+ catheter after completein/ trainin/,
Physicians* $0s* EM)3Ps or EM)3Bs are responsi.le for la.elin/ the IV .a/ and tu.in/ 1ith any
appropriate medication la.els and 45ay of Chan/e4 la.els,

Definitions:
Extravasation: Inadvertent administration of vesicant solution"medication into surroundin/
tissue,
In extremis: A situation in 1hich a patient is near to or at the point of death
Infiltration: Inadvertent administration of non3vesicant solution"medication into surroundin/
tissue,
Intermittent: 6toppin/ and startin/ an infusion that is disconnected and reconnected at intervals,
I: Intraosseous infusion is the process of in7ection directly into the marro1 of the .one, )he
needle is in7ected throu/h the .one8s hard corte9 and into the soft marro1 interior,
I! "ubin#: IV administration sets used to deliver fluids and"or medications via /ravity or
throu/h an IV infusion pump, )hese sets include: primary tu.in/* secondary tu.in/* e9tension
tu.in/* and stopcoc:s,
c(&;#&( Pa/e & of %
Intraosseous Lines
Policies and Procedures:
I$ Insertion of I %Intraosseous& Access Devices
A, Intraosseous (I+) access is intended for patients in e9tremis or those in* or
imminently in dan/er of* cardiopulmonary arrest 1hen rapid vascular access cannot
.e o.tained, )1o peripheral IV attempts should .e tried and documented prior to I+
consideration,
B, I+ is to .e a rapid access route appropriate for administerin/ medications* fluids and
colloids 1hen vascular access cannot .e o.tained,
C, )1o peripheral IV attempts should .e tried and documented prior to I+ consideration
5, +nly physicians and competency trained $0<s and Emer/ency )echnicians may insert
I+ access devices,
E, Preference should .e to place I+ in humeral access site 1ith secondary option of
ti.ial access site,
=, I+ access may .e present in patients 1ho arrive via field Emer/ency Medical
6ervices (EM6),
>, Correct placement and patency is determined .y: the a.ility to flush and smoothly
deliver intravenous (IV) fluid 1ithout any si/ns of e9travasation, )he a.ility to
aspirate .lood or marro1 from intraosseous site may or may not .e present,
?, +nce I+ catheter is inserted* chec: for si/ns of e9travasation of fluid around the I+
insertion site, If s1ellin/ or infiltration is o.served* remove I+ device immediately,
I, Contra3indications for I+ placement sites include: fractured e9tremity of tar/eted
.one* prosthetic 7oint near insertion site* previous attempt at insertion site*
osteoporosis* and infections near insertion site,
II$ I 'edication Administration
A, Appropriate fluiddru/s approved to .e administered throu/h I+: medications*
crystalloids* .lood and .lood products, CA@)I+0: do 0+) infuse: )P0*
Chemotherapy* IV contrast and hypertonic saline,
B, Any infusion set 1ith /ravity drip tu.in/ may reAuire a pressure infusion device to
assist in maintainin/ an adeAuate flo1 rate, A rapid infusion set may .e used via I+
III$ I (ite Assessment and Care
A, Catheter must .e removed 1ithin !' hours or sooner if"1hen peripheral or central
venous access is o.tained,
B, 6ee Appendi9 A for additional care and flushin/ protocols specific to I+ Brand .ein/
utiliBed in the patient
C, 6ecure the I+ device in place* usin/ the I+ sta.iliBer dressin/, If a sta.iliBer dressin/
is not availa.le* may use '9' /auBe on t1o sides of needle to sta.iliBe needle .efore
tapin/ in place,
5, 0+ LAB6 shouldcan .e dra1n throu/h I+ site due to inconsistency 1ith results,
E, )he I+V site and infusion eAuipment 1ill .e chec:ed and documented at least every
four hours$ More freAuent I+ site assessments and documentation may .e necessary
dependin/ on infusion solutions* rates or patient circumstances,
=, Continuously monitor for s1ellin/ and other si/ns of infiltration* e9travasation or
infection and notify M5 if si/ns or symptoms are present, Inspect the site for the
c(&;#&( Pa/e ! of %
Intraosseous Lines
follo1in/ si/ns"symptoms: pain* discomfort* phle.itis* infiltration* infection*
discoloration* sensation chan/es* edema* localiBed s1ellin/* and e9udate, 5ocument
I+ site assessment and care in the medical record,
>, Potential complications of I+ access are: compartment syndrome* e9travasation*
fractures caused .y insertion* osteomyelitis* fat em.olus* necrosis* and infection at the
insertion site,
?, EAuipment Inspection: Inspect and monitor the follo1in/ access eAuipment: catheter*
connections* fluids .ein/ infused* and pump function includin/ flo1 rate,
I, If an I+3related infection is suspected* remove catheter and notify M5,
C, Provide pain relief measures as needed and document patient response,
I!$ I Line Discontinuation
A, 6ee Appendi9 A for removal techniAues specific to I+ Brand .ein/ used,
B, If unsure 1hich I+ .rand is in place* consult vascular access 1e.site
C, Cannula must .e removed 1ith a specific order from the physician 1hen therapy is
completed* !' hours after insertion* 1hen contamination or complication is suspected*
and as soon as other peripheral or central access is o.tained,
&, >ather eAuipment:
>auBe and tape* or Band3Aid
>loves
!, Prior to .e/innin/ procedure* 1ash hands* don /loves
(, 5iscontinue administration of all infusates,
', $emove dressin/ and tape
D, Inspect catheter3s:in 7unction,
%, $emove I+ catheter .y rotatin/ and /ently pullin/ the catheter a1ay from the site
(6ee Appendi9 A for removal techniAues specific to I+ Brand .ein/ used),
;, Verify that catheter is intact, (If not intact* notify physician immediately,)
E, Cover site 1ith sta.iliBer dressin/ or /auBe and tape,
#, 5ocument removal of I+V catheter* intactness of catheter* date and time* and
condition of site on nursin/ flo1 sheet,
&, Continue to monitor site post removal for infection* discoloration* sensation
chan/es* edema* localiBed s1ellin/* and e9udate,
5, I+ catheters are appropriate for use in the emer/ency department* intensive care units*
and procedural care areas only (E$* MIC@* 6IC@* B)IC@* C)IC@* CIC@*
0euroIC@* I$* Cath La.* and +$), )he I+ should .e discontinued prior to
transferrin/ patients to medical"sur/ical units once alternate vascular access has .een
o.tained,
References:
&, Colorado 5epartment of Pu.lic ?ealth and Environment* ?ealth =acilities and Emer/ency
Medical 6ervices 5ivision (!&(), % CC$ &&D3( Chapter )1o 2 $ules Pertainin/ to EM6
Practice and Medical 5irector +versi/ht, (L+E E)
!, 5iamond* L, (!&), Cardiopulmonary $esuscitation and Acute Cardiovascular Life
6upportFA Protocol $evie1 of the @pdated >uidelines, Critical Care Clinics, !(* E;(3EE,
(L+E ;)
c(&;#&( Pa/e ( of %
Intraosseous Lines
(, =ast Infusion 6ystem, 111,fast&sternal,com"a.out3fast&"protocol* accessed '"&("&(, (L+E E)
', >aBin* 0,* Au/era* ?,* Ca.rea* P,* Caulina* C,* Lecarpentiera* E,* and Bertranda* C, !, >aBin*
0,* et al, (!&&), Efficacy and 6afety of the Intraosseous 5evice: +ut3of3?ospital
Implications of a Mana/ement Al/orithm for 5ifficult Vascular Access, Resuscitation, E!*
&!%3&!#, (L+E ()
D, Infusion 0ursin/ 6ociety (!&&), Infusion nursin/ standards of practice: Intraosseous Access
5evises* Journal of Infusion Nursing* ('(&s)* 6E!3E', (L+E ;)
%, Infusion 0ursin/ 6ociety (!#), )he $ole of the $e/istered 0urse in the Insertion of the
Intraosseous Access, Journal of Infusion Nursing (!*&E;3&EE, (L+E ;)
;, Luc:* $, P,* ?aines* C,* and Mull* C, C, (!&), Intraossesous Access, Journal of Emergency
Medicine* (#* '%E3';D, (L+E E)
E, Miller* L, C,* Phil.ec:* ),E,* MonteB* 5,* and 6padaccini* C, C, (!&), A 0e1 6tudy of
Intraossesous Blood for La.oratory Analysis, Archives of Pathology and Laboratory
Medicine* &('* &!D(3&!%, (L+E ()
#, 0/o* A,* +h* C,* Chen* G,* Gon/* 5,* and +n/* M, (!#), Intraosseous Vascular Access in
Adults @sin/ the EH3I+ in an Emer/ency 5epartment, Int Journal of Emergency Medicine,
!* &DD3&%, (L+E ()
&, +n/* M,* Chan* G,* +h* C,* and 0/o* A, (!#), An +.servational* Prospective 6tudy
Comparin/ )i.ial and ?umeral Intraosseous Access @sin/ the EH3I+, he American Journal
of Emergency Medicine, !;* E3&D, (L+E ()
&&, Phillips, (!&), $ecommendations for the @se of Intraosseous Vascular Access for Emer/ent
and 0onemer/ent 6ituations in Various ?ealth Care 6ettin/s, Journal of Infusion Nursing,
((* ('%3(D&! (L+E !)
&!, Von ?off* 5,* Iuhn* C,* Burris* ?,* Miller* L, (!E), 5oes Intraosseous EAual IntravenousJ A
Pharmaco:inetic 6tudy, he American Journal of emergency Medicine, "#, $%&$'! (L+E !)
&(, =ast Infusion 6ystem, 111,fast&sternal,com"a.out3fast&"protocol* accessed '"&("&(, (L+E E)
&', Vidacare, EH3I+ .y vidacare C5, 111,vidacare,com* accessed '"&'"&(, (L+E E)
&D, Von ?off* 5,* Iuhn* C,* Burris* ?,* Miller* L, (!E), 5oes Intraosseous EAual IntravenousJ A
Pharmaco:inetic 6tudy, he American Journal of emergency Medicine, !%* (&3(E! (L+E !)
&%, -aisMedLtd, http:""111,1aismed,com"uniAue3'D,htm* accessed '"&'"&(, (L+E VE)
&;, ViBcarra, (!&), Intraosseous $oute as Alternative Access for Infusion )herapy, Journal of
Infusion Nursing, ((* &%!3&;', (L+E E)
&E, -aisMedLtd, http:""111,1aismed,com"uniAue3'D,htm* accessed '"&'"&(, (L+E E)
c(&;#&( Pa/e ' of %
Intraosseous Lines
&#, APPE05IK A
"ype Infusion Rates
)lus*in#
Protocol Removal "ec*ni+ue
(i,es
Available
Appropriate
(ite
Locations (ite Care

EH3I+
(provided
in @C?
code carts)
Any infusion
set to /ravity
drip rate may
reAuire a
pressure
infusion device
to assist in
maintainin/ an
adeAuate flo1
rate* level one
&ml of
normal
saline
6upport patient<s le/L
simultaneously connect
a sterile luer loc:
syrin/e to the hu. of the
catheter, +nce
connected* rotate the
syrin/e and catheter
cloc:1ise31hile /ently
pullin/, Do not roc: or
.end the catheter 1hile
removin/,
&D> in
&Dmm*
!Dmm and
'Dmm
Pro9imal
humerus
(preferred)*
Pro9imal and
5istal )i.ia
(secondary)*
Pro9imal
humerus
sta.iliBer
dressin/
provided in :it*
or '9' and tape

=ast
6ternal I+
>ravity drip
(3Eml"min,
Pressure Cuff
&!Dml"min,
6yrin/e !D
ml"min,
&ml of
normal
saline
0e1 =A6)& 1ith .lue
tip does not reAuire a
removal tool, 6imply
/rasp the tu.e firmly at
the insertion and pull to
remove, -ith older
=A6)& 1ithout the .lue
tip a remover tool must
.e used,
one siBe
availa.le
+nly
approved
for adult
use
Manu.rium*
midline
&,Dcm .elo1
sternal notch
>auBe

Bone
In7ection
>un
(B,I,>,)
+ptimal flo1
maintained
1ith pressure
.a/ inflated to
( mm ?/
=lush 1ith
!3(ml of
normal
saline prior
to initial
in7ection of
fluids or
dru/s, After
administrati
on of fluids
or dru/s
flush 1ith
&3!ml of
normal
saline,
Match the sAuare hole
on the safety latch to the
sAuare portion of the
cannula then t1ist
/ently and pull up and
out of the .one,
&E/ and
&D/ in ,
Dcm and
&,Dcm
)i.ia
tu.erosity
alternate site:
?umerus
Aseptic
techniAue, Place
security latch at
.ase of needle*
this acts as an
anchor and
should .e left in
place in until
removal,

c(&;#&( Pa/e D of %
Intraosseous Lines
"ype Infusion Rates
)lus*in#
Protocol Removal "ec*ni+ue
(i,es
Available
Appropriate
(ite
Locations (ite Care
Coo: I+ @se e9tension
tu.in/ to
decrease
needle
manipulation
and potential
displacement
May reAuire
use of a
pressure .a/
to maintain
flo1
>ently rotate the
cannula and 1ithdra1
smoothly,
&'/* &%/
and &E/ in
(cm and
'cm
)i.ia
Alternate
site: femur
Continuously
monitor for
s1ellin/ and
other si/ns of
e9travasation,

MM Please note* La. levels are not accurate and inconsistentconsistently accurate 1ith I+*
therefore 5+ 0+) send la.s dra1n from I+ device
c(&;#&( Pa/e % of %