RECOMMENDATIONS FOR THE USE OF

INTRAOSSEOUS VASCULAR ACCESS FOR EMERGENT

AND NONEMERGENT SITUATIONS IN VARIOUS

HEALTHCARE SETTINGS: A CONSENSUS PAPERThis article is being co-published in the Journal of Infusion Nursing, the Journal of Pediatric Nursing, and Critical Care Nurse

Authors: The Consortium on Intraosseous Vascular Access in Healthcare Practice: Lynn Phillips, Lucinda Brown,Teri Campbell, Julie Miller, Jean Proehl, Barbara Youngberg

Purpose

In recognition of the value of intraosseous (IO) vascularaccess in patient resuscitation and stabilization, leadingnational and international organizations have publishedposition papers that have served to change the standard ofcare for emergency vascular access. Among them are theAmerican Heart Association (AHA), addressing vascularaccess in cardiac arrest patients,1 the International Commit-tee on Resuscitation (ILCOR),2 the European ResuscitationCouncil,3 the Infusion Nurses Society (INS),4 the NationalAssociation of EMS Physicians (NAEMSP),5 with theEmergency Nurses Association (ENA) and the AmericanAssociation of Critical-Care Nurses (AACN) endorsingthe INS position paper.6,7 These professional societiesrecognized that IO access may provide significant time sav-ings that could benefit patients in emergent situations bydecreasing the time required to achieve access and the time

required to administer necessary fluids and medications.The AHA concluded that intravenous (IV) and IO admin-istration have equal, predictable drug delivery and pharma-cologic effects. Both AHA and European ResuscitationCouncil guidelines state that IO access should be the firstalternative to failed IV access.1,2

Given the well-established use of IO in the emergencysetting, the Consortium chose to go beyond its use in resus-citative settings to explore the evidence supporting IO usewherever vascular access is medically necessary or difficult toachieve in all settings. This includes, but is not limited to,patients in the intensive care unit, on high acuity/progressivecare floors, on the general medical floor, in pre-procedure sur-gical settings where lack of vascular access can delay surgery,and in chronic care and long-term care settings.

Definitions

For purposes of this paper, an emergent patient situationis defined as a sudden unforeseen event demandingimmediate action without which the patient is in dangerof increasing morbidity or mortality.

A nonemergent patient situation refers to the potential ofan eventual increase in patient morbidity or mortality if actionis not taken.

Intraosseous Vascular Access Overview

Intraosseous vascular access has received considerableattention as an effective first alternative to failed ordelayed peripheral or central IV access in emergent situa-tions. The technique involves the placement of a vasculardevice with the tip of the IO catheter in the bone matrixwith a dwell time of 24 hours. Delivery of crystalloids,colloids, or medications through this catheter immedi-ately infuse into the systemic circulation via the bonemarrow cavity.

Lynn Phillips, Infusion Nurses Society and Consortium Chair.

Lucinda Brown, Society of Pediatric Nurses.

Teri Campbell, Air and Transport Nurses Association.

Julie Miller, American Association of Critical-Care Nurses.

Jean Proehl, Emergency Nurses Association.

Barbara Youngberg, Visiting Professor of Health Law and Policy, BeazleyInstitute for Health Law and Policy, Loyola University Chicago College of Law.

An educational grant was provided by Vidacare Corporation to the InfusionNurses Society for a meeting of the authors of this paper. Editorial control ofthe paper’s content rested solely with the authors.

This paper was also published in the Journal of Infusion Nursing, Volume 33,Issue 6.

For correspondence, write: Jean A. Proehl, 216 Tandy Brook Rd, Cornish,NJ 03745

J Emerg Nurs 2010;36:551-6.

0099-1767/$36.00

Copyright © 2010 by the Infusion Nurses Society. Published by Elsevier Inc.All rights reserved.

doi: 10.1016/j.jen.2010.09.001

C L I N I C A L

November 2010 VOLUME 36 • ISSUE 6 WWW.JENONLINE.ORG 551

Background

Using the bone marrow space (described as a “non-collapsible vein”) for emergency purposes has a long his-tory of research dating back to the 1920s when Drinkerand Lund described the sternum as a potential site fortransfusions.8 Not long after, Papper described access tothe marrow space for the use of intravenous fluids.9

Investigators since then have verified that fluids and drugsadministered through the intraosseous space reach thecentral circulation as quickly as central lines and fasterthan peripheral lines10,11 and that, in many cases, it waslife saving.

The use of the IO space for the purpose of patientresuscitation and stabilization reached a peak duringWorld War II, when it was used by medics to resuscitatesoldiers dying from hemorrhagic shock. Following thewar, the technique fell out of favor because those whoused it in the military setting were returned to the civilianpopulation, and since there was no organized emergencymedical system at the time, their skills were not transferred.IO placement fell out of use for a considerable time inmany countries.

This changed in the early 1980s when a pediatricianfrom the Cleveland Clinic, visiting India during a choleraepidemic, observed many dehydrated children being resus-citated using IO devices. His famous editorial, “My King-dom for an Intravenous Line,”12 led to IO access becominga standard in pediatric advanced life support (PALS) in1988, where it remains to the present.13

The use of IO access in adults by comparison haslagged until recently. Its use in adults has increased inthe last several years. There are several reasons for thisincrease in use, among them an evolution in technologythat has made IO insertion possible in the dense adultbone cortex, as well as its being a vascular access tech-nique that is an easily learned and retained skill.14 Datahave shown that rapid absorption of fluids by IO infu-sion into the central circulation is equivalent to or bet-ter than that resulting from peripheral IV access.15 TheJoint Commission’s discouragement of the use offemoral lines for vascular access16 and national initia-tives that curb the unnecessary use of central lines17

lend credence to use of IO access as an alternative foradult patients in emergent situations. These initiativesresult from an increasing focus on costly and life-threa-tening catheter-associated infections, notably thosecaused by central lines. The Centers for Disease Controland Prevention (CDC) reports 248,000 bloodstreaminfections per year, costing between $2 billion and $9billion, with 31,000 deaths per year.18 The necessary

expertise for placing central lines may not be availableat all times, in all settings, making an alternative suchas IO access especially valuable.

Clinical Considerations

OPTIONS FOR VASCULAR ACCESS

It is recognized that lack of immediate vascular access canlead to unnecessary morbidity or mortality. To achieveaccess when peripheral IV access is delayed or impossible,the choices are few for patients with limited vascular access,which may result in difficult access or no access at all.Options include external jugular and peripherally insertedcentral catheters and non-tunneled percutaneous centralcatheters. While radiographic confirmation of tip place-ment is not required for IO devices, it is a requirementfor central catheters, which adds time and expense to theinitiation of care. External jugular sites have high malposi-tion rates19 and are particularly difficult to insert in obesepatients and in infants because of their extremely shortnecks. They are also associated with several serious compli-cations, including laceration of the deeper internal jugularvein and infection.20

For both older adult patients and pediatric patients whoare dehydrated, hypodermoclysis, or clysis, is a possible substi-tute for conventional IV access, but it has some limitations,among them a tendency to enhance adverse events associatedwith co-administered drug products.21 Thus clysis may havelimited use in patients in whom the administration of bothfluid and drugs may be required.

The CDC recommends selecting intravenous cathetersand insertion sites with the lowest risk of complications(infectious and non-infectious) appropriate for the therapeu-tic goal.22 Given the historical low complication rates of IOvascular access (see “Complications of Intraosseous Access”),it is a viable alternative for patients with difficult vascularaccess who are in need of medication and fluids over theshort term but for whom immediate administration of theseproducts would reduce morbidity and mortality, and forwhom peripheral IV access is not available. It should alsobe noted that IO devices provide the added benefits of allow-ing bone marrow samples to be drawn for laboratory analysisfor blood sampling23,24 and for the delivery of radiologiccontrast dyes.25 Most medications that can be infused safelythrough peripheral IV catheters can also be safely infusedthrough IO devices.

CLINICAL SITUATIONS IN WHICH IO ACCESS MAYBE CONSIDERED

The following clinical situations represent patient groupsin whom vascular access is notably difficult or who

CLINICAL/Phillips et al

552 JOURNAL OF EMERGENCY NURSING VOLUME 36 • ISSUE 6 November 2010

need access repeatedly but characteristically have limitedvascular access. Intraosseous access can be consideredclinically appropriate on the basis of a short-term needfor patients:

• with chronic disease who have been admitted to thehospital for treatment of a medical event, eg, the dete-riorating patient with chronic obstructive pulmonarydisease (COPD).

• with limited vascular access due to aggressive treatmentmodalities, eg, fistulas, grafts, shunts, mastectomies, ormultiple central line placements.

• for whom Rapid Response Teams are called in order toprevent an emergent situation and in whom obtainingperipheral or central IV access is difficult.

• who experience an unexpected medical event thatcauses their peripheral or central IV device to becomenon-functional, eg, infiltration or occlusion, and diffi-cult to reestablish.

• who have limited peripheral access due to morbidobesity.

• who suffer from intractable pain.• who are in the early stages of sepsis.• who are receiving palliative or hospice care.• who are undergoing anesthesia and experience pro-longed, difficult, or failed IV access.26,27

Types of Devices

The evolution of IO device technology through which IOvascular access can be obtained has been dramatic over thepast several years, making the procedure relatively easy toperform with appropriate education and training. Severaldevices have been cleared by the US Food and DrugAdministration for IO vascular access for 24-hour use.There are 3 different needle placement methodologies forintraosseous access:

Manual. Manually inserted needles have been availablein the United States since the 1940s. These manual needlesare hollow steel needles with removable trocars that preventbone fragments from plugging the needles during insertion.There are limitations of the steel manual needles due to dif-ficulty accessing dense adult bone.

Impact driven. There are 2 types of impact-drivendevices. One of these devices, originally designed for sternalaccess, has several needle probes to accurately locate thedepth of the sternum. When pressure is applied, the centralneedle extends into the sternal medullary cavity. A possiblelimitation to this form of device is lack of access to the ster-num in resuscitation situations. A second type uses aspring-loaded injector mechanism that fires the IO needleinto the medullary space of the tibia. Both of these devices

must be appropriately stabilized to prevent injury to thepatient or clinician.

Drill powered. This device is a battery-operated, drill-based technology designed to access the intraosseousspace to an appropriate depth. It consists of a driverand a needle set designed for insertion into the IO space.Different needle sizes are used depending on patient age,weight in kilograms, and tissue depth over the land-marks. The precise needle-to-bone ratio allows efficientinsertion and is designed to minimize trauma to the boneduring insertion.

Head-to-head comparisons of specific IO devices existin the literature.28,29

Contraindications to Intraosseous Access

Intraosseous access should be avoided in the followingsituations:

• Fractures in the same extremity as the targeted bone• Previous surgery involving hardware in the bone tar-geted for IO access

• Infection at the insertion site or within the targetedbone

• Local vascular compromise• Previous failed IO insertion within 24 hours in the tar-geted bone

• Inability to locate the landmarks1,27,30

Bone disease such as osteogenesis imperfecta, osteope-trosis, and severe osteoporosis may be a contraindicationdepending on the device.31

Complications of Intraosseous Access

Few complications are reported in connection with IOaccess. Most are avoidable with proper education and train-ing. Others are related to the type of device insertion tech-nique.28 Complications associated with IO access includeextravasation from dislodgment, iatrogenic fracture, growthplate injury, infection, fat emboli, compartment syndrome,and osteomyelitis.28

Early case reports identified osteomyelitis as a complica-tion of IO access. Although this represents a serious adverseevent, the incidence of osteomyelitis after IO placement israre. The largest study examining this complication—ameta-analysis of the literature of 30 IO studies that included4,230 patients—revealed an incidence of osteomyelitis ofonly 0.6%; complications were more likely to occur withprolonged infusion or if bacteremia was present during thetime of insertion.32 Since this 1985 study, only single casestudies have been reported, all in pediatric patients.33-37 Themost commonly reported complication is extravasation,38

Phillips et al/CLINICAL

November 2010 VOLUME 36 • ISSUE 6 WWW.JENONLINE.ORG 553

which is generally the result of poor insertion technique,inadequate device stabilization, or device design.

Although the historical risk of introducing infectioninto the soft tissue during IO insertion is small, there is apotential that the incidence may increase if the procedureis practiced by a wider spectrum of clinicians and if the nee-dles are purposely left in place for longer than 24 hours.1 Inthe absence of evidence, the Consortium therefore advisesthat when the IO needle is inserted in this unique groupof patients, the clinician follow Standard Precautions andaseptic technique as established in organizational policiesand procedures, and follow AHA guidelines for dwell times.1

Other Considerations

PAIN IN THE CONSCIOUS PATIENT

Pain is often discussed as a concern either upon enteringthe intraosseous space or during infusion of fluids andmedications under pressure. Most patients in need of emer-gency vascular access are unconscious or have severelyaltered mental states. However, several studies have beenconducted to include conscious patients in order to assesspain associated with the procedure both during insertionand infusion. Insertion pain has been reported by severalinvestigators to have a mean Visual Analog Scale, orVAS, score between 2.5 and 3.5, similar to scores asso-ciated with peripheral and central device placement.39-41

Infusion pain has also been addressed. In a large,1128-case series using the powered drill device, the investigatorsfound that, in most cases, patient pain level upon infusionof fluids could be substantially reduced by injecting 0.5mg/kg of preservative-free lidocaine through the IO port priorto infusion.30 In another study of 24 patients receiving tibialinsertion, investigators recommended using a prior flush of20 mg to 50 mg of 2% preservative-free lidocaine throughthe IO device.42 When infused properly, the lidocaine actsas a local anesthetic, thus blocking the pain sensation. Aswith all procedures, pain is individualized, and additionaldosing may be required. No data are available regardingpain in connection with manual or spring-loaded devices.

EDUCATION AND TRAINING

To insert and maintain an IO device in a patient, theclinician must demonstrate adequate knowledge and psy-chomotor skill competency in the procedure. This compe-tency should include aseptic technique and appropriateinsertion, care and maintenance, and replacement andremoval procedures. In order for IO vascular access tobecome a standard of care within clinical practice in allpractice settings, education and training should be inte-grated into core competency curricula.

ECONOMICS

In an era of increasing focus on cost, economic evaluationof new technologies is an essential part of technologyassessment. The cost of IO devices and needles shouldbe compared with the cost of central line kits, ultrasoundevaluation, and human resources required for their insertion.Risk management and patient safety are additional aspects ofeconomic considerations. Central lines are associated withinfection and increased length of hospital stays.43 Hospital-acquired infections have been placed on a list of “neverevents” by the Centers for Medicare & Medicaid Services(CMS), and both CMS and large private insurers will notfully reimburse hospitals for catheter-related infections.44

When weighing economic factors, the potential complica-tions of therapeutic strategies should be considered.

RISK MANAGEMENT AND PATIENT SAFETY

In an era when liability concerns continue to drive manyclinical decisions, it is worth noting that delays in treat-ment are often cited as the proximate cause of injury lead-ing to malpractice claims. In patients who present to amedical facility or provider in need of immediate fluidresuscitation or drug administration and for whom vascularaccess cannot be readily or safely obtained, IO access mayprovide a safe and viable alternative and treatment defense.With existing evidence citing the clinical efficacy of IOaccess and the ease and speed of insertion,14,28,29,31,39 clin-icians should consider using this method of infusion deliv-ery. Clinicians will have to carefully assess the patient’scondition, determine if his or her condition requiresimmediate intervention including fluids, medications, orboth, and then determine if IO access provides the safestand most effective treatment option.

DATA

The literature on the use of IO vascular access is abundant.More than 20 pharmacokinetic studies indicate that IOaccess delivers fluids and medications as quickly as thoseadministered intravenously.15 The rapidity of absorptionof medications and fluids via the intraosseous route is wellestablished in the human subject literature. Equally wellestablished is the relative lack of complications comparedwith those of alternative methods of vascular access.Data-gathering will continue as the intraosseous approachbecomes more established in a variety of health care set-tings. Currently there is a larger source of data on emergentpatient scenarios than those of in-patient alternative IOaccess. Clinical studies of IO access that focus on deploy-ment in nonemergent clinical situations are encouraged. Inaddition, the establishment of national criteria (CDC/National Healthcare Safety Network [NHSN]) for defining

CLINICAL/Phillips et al

554 JOURNAL OF EMERGENCY NURSING VOLUME 36 • ISSUE 6 November 2010

an IO-hospital associated infection is encouraged, andorganizations should develop methods to capture datarelated to IO access and report IO placement to facilityadministrators and nationally to CDC. However, the cur-rent lack of data should not be regarded as a barrier to useof a proven technique in achieving vascular access in atimely way.

CONSTITUENCY EDUCATION

It is important that groups such as the Agency for HealthCare Research and Quality (AHRQ) and The Joint Com-mission (TJC), as well as professional associations repre-senting clinicians whose patients have vascular accessissues, actively support IO vascular access in their practicerecommendations. Such consideration could encourage IOdevice use in appropriate situations.

Summary of Recommendations

The Consortium on Intraosseous Vascular Access in Health-care Practice has reached a consensus on the following:

1. Intraosseous vascular access should be considered as analternative to peripheral or central IV access in a varietyof health care settings, including the intensive care unit,on high acuity/progressive care floors, on the general med-ical floor, in pre-procedure surgical settings where lack ofvascular access can delay surgery, and in chronic care andlong-term care settings, when an increase in patient mor-bidity or mortality is possible.

2. Intraosseous vascular access should be considered as part ofan algorithm for patients treated by Rapid Response Teamsin which vascular access is difficult or delayed.

3. A new algorithm that includes the intraosseous routeshould be developed for assessing the appropriate routeof vascular access.

4. For patients not requiring placement of central lines eitherfor long-term vascular access and/or hemodynamic moni-toring, IO access should be considered as the first alterna-tive to failed peripheral IV access.

5. Techniques of IO catheter placement and infusion admin-istration should be a standard part of the medical schooland nursing school curriculum.

6. In evaluating the economic implications of adopting IOtechnology, the following should be considered: theexpense of diagnostic tools to guide and confirm placement,the cost of human resources, the known and unknown risksto patient safety, and the cost of complications related todelayed treatment.

7. Organizational policies, procedures, and protocols thatestablish the responsibility of insertion, maintenance,and removal of IO access devices should be developed.

8. Further research should be conducted on, but not limitedto, the safety and efficacy of IO use in all practice settings,its economic impact on patient care, and to support the useof IO access in all health care settings.

The Consortium recognizes that support of this prac-tice change requires a practice shift in all clinical settings.However, the change could result in an appropriate vascu-lar access solution for a growing population of patients withdifficult vascular access. The Consortium believes thatembracing patient-centered care is a vital step in improvingsafety and quality. This is a shared goal of all those involvedin health care.

Acknowledgment

The Consortium wishes to thank Susan Meister, president of Communicore,for her facilitation of the group process and assistance with draft development.

REFERENCES1. American Heart Association. American Heart Association guidelines for

cardiopulmonary resuscitation and emergency cardiovascular care: man-agement of cardiac arrest. Circulation. 2005;(pt 7.2):IV-58–IV-66.

2. International Liaison Committee on Resuscitation (ILCOR). Interna-tional consensus of cardiopulmonary resuscitation and emergency cardi-ovascular care science with treatment recommendations: advanced lifesupport. Resuscitation. 2005;67(pt 4):213-47.

3. European Resuscitation Council. European resuscitation guidelines.Resuscitation. 2005;6751:51-2. http://www.erc.edu/index.php. AccessedJuly 3, 2010.

4. Infusion Nurses Society [position paper]. The role of the registerednurse in the insertion of intraosseous access devices. J Infus Nurs.2009;32(4):187-8.

5. Fowler R, Gallagher JD, Isaacs MS, et al. [resource document to theNAEMSP position statement]. The role of intraosseous vascular accessin the out-of-hospital environment. Prehosp Emerg Care. 2007;11:63-6.

6. Emergency Nurses Association. ENA-supported statements. http://www.ena.org. Published August 2009. Accessed July 3, 2010.

7. American Association of Critical-Care Nurses. American Association ofCritical-Care Nurses endorses nurses’ expanded role in use of IO accessdevices. http://www.aacn.org/WD/PressRoom. Published June 21,2010. Accessed July 3, 2010.

8. Drinker CK, Drinker KR, Lund CC. The circulation of the mammalianbone marrow. Am J Physiol. 1922;62:1-92.

9. Papper EM. Bone marrow route for injecting fluids and drugs into thegeneral circulation. Anesthesiology. 1942;3:307-13.

10. Hoskins S, Nascimiento P, Espana J, et al. Pharmacokinetics of intraoss-eous drug delivery during CPR. Shock. 2005;23:35.

11. Hoskins SL, Stephens CT, Kramer GC. Efficacy of intraosseous drugdelivery during cardiopulmonary resuscitation in swine. Proceedingsfrom the American Heart Association; November 13-16, 2005; Dallas, TX.

12. Orlowski J. My kingdom for an intravenous line. Am J Dis Child.1984;138:803.

13. American Heart Association. American Heart Association guidelines forcardiopulmonary resuscitation and emergency cardiovascular care: pedia-tric advanced life support. Circulation. 2005;112(pt 12):IV-167-IV-187.

Phillips et al/CLINICAL

November 2010 VOLUME 36 • ISSUE 6 WWW.JENONLINE.ORG 555

14. Dubick MA. A review of intraosseous vascular access: current status andmilitary applications. Military Med. 2000;165(7):552-9.

15. Von Hoff DD, Kuhn JG, Burris HA, Miller LJ. Does intraosseous equalintravenous? A pharmacokinetic study Am J Emerg Med. 2008;26:31-8.

16. The Joint Commission. The Joint Commission accreditation program: hos-pital 2009: National Patient Safety Goals, 2009. www.jointcommission.org.Accessed July 3, 2010.

17. National Hospital Association. National implementation of the compre-hensive-based safety program (CUSP) to reduce central line associatedblood stream infections (CLABS) in the intensive care unit. AmericanHospital Association, Health Research & Educational Trust; 2009.http://www.onthecuspstophai.org/. Accessed July 3, 2010.

18. Centers for Disease Control and Prevention. Public Health GrandRounds: Towards the Elimination of Healthcare-Associated Infections.National Center for Preparedness, Detection, and Control of InfectiousDiseases; 2009. http://www.cdc.gov/about/grand-rounds/archives/2009/download/GR-101509.pdf. Accessed July 3, 2010.

19. Trerotola S, Thompson J, et al. Analysis of tip malposition and correc-tion in peripherally inserted central catheters placed at bedside by a dedi-cated nursing team. J Vascular Intervent Radiol. 2009;18(4):513-8.

20. Ranishin WJ, Paradowski L. Triple lumen central venous access via theexternal jugular vein. Chest. 1990;98:1040-1.

21. Pirrello R, Chen CT, Thomas SH. Initial experiences with subcutaneousrecombinant human hyaluronidase. J Palliative Med. 2007;10(4):861-4.

22. Centers for Disease Control and Prevention (CDC). Guidelines for thePrevention of Intravascular Catheter-related Infection. MMWR MorbMortal Wkly Rep. 2002;51(10):1-29.

23. Hurren J. Can blood taken from intraosseous cannulations be used forblood analysis? Burns. 2000;26(8):727-30.

24. Miller L, Philbeck T,Montez D, Spadaccini C. A new study of intraosseousblood for CBC and chemistry profile. Ann Emerg Med. 2009;54(3):S59.

25. Cambry EJ, Donaldson JS, Shore RM. Intraosseous contrast infusion:efficacy and associated findings. Pediatr Radiol. 1997;27:892-3.

26. Neuhaus D, Weiss M, Engelhardt T, et al. Semi-elective intraosseousinfusion after failed intravenous access in pediatric anesthesia. PediatrAnesth. 2010;20:168-71.

27. Tobias JD, Ross AK. Intraosseous infusions: a review for the anesthesiol-ogist with a focus on pediatric use. Anesth Analg. 2010;2:391-401.

28. Calkins MD, Fitzgerald G, Bentley TB, et al. Intraosseous infusiondevices: a comparison for potential use in special operations. J Trauma.2000;48:70-4.

29. Davidoff J, Fowler R, et al. Clinical evaluation of adult intraosseous sys-tem for adults: a prospective, 250 patient, multi-centered trial. JEMS.2005;23.

30. Fowler RL, Pierce A, Nazeer S, et al. Powered intraosseous insertionprovides safe and effective vascular access for emergency patients. AnnIntern Med. 2008;52(4):S152.

31. Wayne MA. Intraosseous vascular access in emergency medicine. EurCrit Care Emerg Med. 2009;1:33-6.

32. Rosetti V, Thompson BM, Miller J, et al. Intraosseous infusion: an alter-native route for pediatric intravenous access. Ann Emerg Med. 1985;14:885-8.

33. Platt SL, Notterman DA, Winchester P. Fungal osteomyelitis andsepsis from intraosseous infusion. Pediatr Emerg Care. 1993;9(3):149-50.

34. Rosovsky M, FitzPatrick M, Goldfarb CR, Finestone H. Bilateral osteo-myelitis due to intraosseous infusion: case report and review of the Eng-lish-language literature. Pediatr Radiol. 1994;24:72-3.

35. Barron BJ, Tram JD, Lamki L. Scintigraphic findings of osteomyelitisafter intraosseous infusion in a child. Clin Nucl Med. 1994;4:307-8.

36. Stoll E, Golej G, Burda M, et al. Osteomyelitis at the injection site ofadrenalin through an intraosseous needle in a 3-month-old infant.Resuscitation. 2002;53:315-8.

37. Dogan A, Irmak H, Harman M, et al. Tibial osteomyelitis followingintraosseous infusion: a case report. Acta Orthop Traumatol Turc.2004;38(5):357-60.

38. LaSpada J, Kissoon N, Melker R, et al. Extravasation rates and compli-cations of intraosseous needles during gravity and pressure infusion. CritCare Med. 1995;23(12):2023-8.

39. Horton MA, Beamer C. Powered intraosseous insertion provides safeand effective vascular access for pediatric emergency patients. PediatrEmerg Care. 2008;24(6):347-50.

40. Philbeck TE, Miller LJ, Montez D. Pain management during intraoss-eous infusion through the proximal humerus. Ann Emerg Med. 2009;54(3):S128.

41. Paxton JH, Knuth TE, Klausner HA. Humeral head intraosseous inser-tion: the preferred emergency venous access. Ann Emerg Med. 2008;52(4):S58.

42. Ong MEH, Chan YH, Oh JJ, et al. An observational, prospective studycomparing tibial and humeral intraosseous access using the EZ-IO. Am JEmerg Med. 2009;27:8-15.

43. Marschall J, Mermel LA, Classen D, et al. Strategies to prevent centralline-associated bloodstream infections in acute care hospitals. InfectControl Hosp Epidemiol. 2008;29:S22-S230.

44. Centers for Medicare & Medicaid Services. Final Rule. http://www.cms.gov/AcuteInpatientPPS/IPPS2009/itemdetail.asp?filterType=none&filterByDID=0&sortByDID=1&sortOrder=ascending&itemID=CMS1220745&intNumPerPage=10. Accessed July 3, 2010.

CLINICAL/Phillips et al

556 JOURNAL OF EMERGENCY NURSING VOLUME 36 • ISSUE 6 November 2010