Petitpas et al. Critical Care (2016) 20:102
DOI 10.1186/s13054-016-1277-6
RESEARCH Open Access
Use of intra-osseous access in adults: a
systematic review
F. Petitpas1,2, J. Guenezan3*, T. Vendeuvre4, M. Scepi2,3, D. Oriot2,5 and O. Mimoz1,3
Abstract
Background: Indications for intra-osseous (IO) infusion are increasing in adults requiring administration of fluids
and medications during initial resuscitation. However, this route is rarely used nowadays due to a lack of
knowlegde and training. We reviewed the current evidence for its use in adults requiring resuscitative procedures,
the contraindications of the technique, and modalities for catheter implementation and skill acquisition.
Methods: A PubMed search for all articles published up to December 2015 was performed by using the terms
“Intra-osseous” AND “Adult”. Additional articles were included by using the “related citations” feature of PubMed or
checking references of selected articles. Editorials, comments and case reports were excluded. Abstracts of all the
articles that the search yielded were independently screened for eligibility by two authors and included in the
analysis after mutual consensus. In total, 84 full-text articles were reviewed and 49 of these were useful for
answering the following question “when, how, and for which population should an IO infusion be used in adults”
were selected to prepare independent drafts. Once this step had been completed, all authors met, reviewed the
drafts together, resolved disagreements by consensus with all the authors, and decided on the final version.
Results: IO infusion should be implemented in all critical situations when peripheral venous access is not easily
obtainable. Contraindications are few and complications are uncommon, most of the time bound to prolonged
use. The IO infusion allows for blood sampling and administration of virtually all types of fluids and medications
including vasopressors, with a bioavailability close to the intravenous route. Unfortunately, IO infusion remains
underused in adults even though learning the technique is rapid and easy.
Conclusions: Indications for IO infusion use in adults requiring urgent parenteral access and having difficult
intravenous access are increasing. Physicians working in emergency departments or intensive care units should
learn the procedures for catheter insertion and maintenance, the contraindications of the technique, and the
possibilities this access offers.
Keywords: Emergency, Intensive care unit, Safety, Skill acquisition
Background infusion is shorter and has a higher success rate on
In patients experiencing shock, severe dehydration, car- first attempt than other routes [2, 3]. Moreover, in
diac arrest, major trauma or airway compromise, and hav- patients experiencing cardiac arrest, the procedure
ing difficult peripheral intravenous (IV) access because of does not require stopping cardiopulmonary resuscita-
edema, obesity, burns, medical history of IV drug abuse or tion and therefore may improve patient survival.
others, physicians have three choices to administer fluids IO infusion is a rapid and safe method for obtaining
and medication during initial resuscitation: insertion of a parenteral access in patients with difficult venous access.
central venous catheter, insertion of an ultrasound-guided Pioneered in 1922 by Drinker and colleagues [4], this ac-
peripheral venous catheter [1], or placement of an intra- cess was not used to benefit peripheral IV until the
osseous (IO) device. In this setting, procedure for IO 1980s. Pediatricians have used this route for three de-
cades in frequent emergency situations like hypovolemic
* Correspondence: shock in dehydrated infants. In adults, IO access is less
3
Emergency Department, University Hospital of Poitiers, 86021 Poitiers,
France frequently used. However, it has been recommended for
Full list of author information is available at the end of the article
© 2016 Petitpas et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
, Petitpas et al. Critical Care (2016) 20:102 Page 2 of 9
about 10 years in the case of failure of peripheral IV line authors independently reviewed the full text of the
placement during resuscitation [5]. Unfortunately, physi- remaining 84 records to select those useful for answer-
cians do not frequently perform this procedure despite ing the following question: when, how, and for which
the availability of new mechanical devices with high population should an IO infusion be used in adults. Fi-
success rate after brief training [6]. Yet, IO access is the nally, a total of 49 records were retained by mutual con-
quickest way to establish access for rapid infusion of sensus, and pertinent data were extracted to prepare
fluids, drugs, and blood products in emergency situa- independent drafts. Once this step had been completed,
tions as well as for cardiac resuscitation [7]. all authors met, reviewed the drafts together, resolved
The aim of this systematic review is to summarize the disagreements by consensus with all the authors, and de-
most relevant information on IO infusion in adults to cided on the final version.
promote its use by physicians working in intensive care
units and emergency departments. Results and Discussion
Historical background and recommendations for IO
Methods access use
A PubMed search for all articles published up to December In 1922, Drinker described the marrow of a mammalian
2015 was performed by using the terms “Intra-osseous” bone as a “non-collapsible vein” [4]. In 1934, Josefson
AND “Adult” (Title/Abstract), which returned 194 records used for the first time an IO access in humans via ster-
(Fig. 1). Retrieval was not limited in time, but only nal location to administer liver concentrate in patients
manuscripts in English or French were selected. Edi- with pernicious anemia [8]. Then, in 1940, Tocantins
torials, comments, and case reports were excluded. and O’Neill described successful administration of blood,
Additional articles were included by using the “related saline solutions and glucose using an IO access in
citations” feature of PubMed. The references of the pediatric patients [9]. IO access was then forgotten by
included articles were reviewed to ensure no relevant physicians and reappeared in the 1980s for children only.
articles had been missed. Finally, the most recent re- It took another two decades before recommendations
views or guidelines on IO or peripheral IV infusion for IO access were included in the 2005 American Heart
were searched. In total, 25 more records were added. Association guidelines for cardiopulmonary resuscitation
Abstracts of the 219 articles that the search yielded and emergency cardiovascular care for adults [10]. Their
were reviewed independently by two authors (FP and last guidelines published in 2015 highlighted the place of
JG) and 135 of them out of scope of this review or IO access when IV access is not readily available in
concerning only children were excluded. The same two adults [5]. Moreover, it is pointed out that IO or IV drug
Fig. 1 Flow diagram of studies selection
DOI 10.1186/s13054-016-1277-6
RESEARCH Open Access
Use of intra-osseous access in adults: a
systematic review
F. Petitpas1,2, J. Guenezan3*, T. Vendeuvre4, M. Scepi2,3, D. Oriot2,5 and O. Mimoz1,3
Abstract
Background: Indications for intra-osseous (IO) infusion are increasing in adults requiring administration of fluids
and medications during initial resuscitation. However, this route is rarely used nowadays due to a lack of
knowlegde and training. We reviewed the current evidence for its use in adults requiring resuscitative procedures,
the contraindications of the technique, and modalities for catheter implementation and skill acquisition.
Methods: A PubMed search for all articles published up to December 2015 was performed by using the terms
“Intra-osseous” AND “Adult”. Additional articles were included by using the “related citations” feature of PubMed or
checking references of selected articles. Editorials, comments and case reports were excluded. Abstracts of all the
articles that the search yielded were independently screened for eligibility by two authors and included in the
analysis after mutual consensus. In total, 84 full-text articles were reviewed and 49 of these were useful for
answering the following question “when, how, and for which population should an IO infusion be used in adults”
were selected to prepare independent drafts. Once this step had been completed, all authors met, reviewed the
drafts together, resolved disagreements by consensus with all the authors, and decided on the final version.
Results: IO infusion should be implemented in all critical situations when peripheral venous access is not easily
obtainable. Contraindications are few and complications are uncommon, most of the time bound to prolonged
use. The IO infusion allows for blood sampling and administration of virtually all types of fluids and medications
including vasopressors, with a bioavailability close to the intravenous route. Unfortunately, IO infusion remains
underused in adults even though learning the technique is rapid and easy.
Conclusions: Indications for IO infusion use in adults requiring urgent parenteral access and having difficult
intravenous access are increasing. Physicians working in emergency departments or intensive care units should
learn the procedures for catheter insertion and maintenance, the contraindications of the technique, and the
possibilities this access offers.
Keywords: Emergency, Intensive care unit, Safety, Skill acquisition
Background infusion is shorter and has a higher success rate on
In patients experiencing shock, severe dehydration, car- first attempt than other routes [2, 3]. Moreover, in
diac arrest, major trauma or airway compromise, and hav- patients experiencing cardiac arrest, the procedure
ing difficult peripheral intravenous (IV) access because of does not require stopping cardiopulmonary resuscita-
edema, obesity, burns, medical history of IV drug abuse or tion and therefore may improve patient survival.
others, physicians have three choices to administer fluids IO infusion is a rapid and safe method for obtaining
and medication during initial resuscitation: insertion of a parenteral access in patients with difficult venous access.
central venous catheter, insertion of an ultrasound-guided Pioneered in 1922 by Drinker and colleagues [4], this ac-
peripheral venous catheter [1], or placement of an intra- cess was not used to benefit peripheral IV until the
osseous (IO) device. In this setting, procedure for IO 1980s. Pediatricians have used this route for three de-
cades in frequent emergency situations like hypovolemic
* Correspondence: shock in dehydrated infants. In adults, IO access is less
3
Emergency Department, University Hospital of Poitiers, 86021 Poitiers,
France frequently used. However, it has been recommended for
Full list of author information is available at the end of the article
© 2016 Petitpas et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
, Petitpas et al. Critical Care (2016) 20:102 Page 2 of 9
about 10 years in the case of failure of peripheral IV line authors independently reviewed the full text of the
placement during resuscitation [5]. Unfortunately, physi- remaining 84 records to select those useful for answer-
cians do not frequently perform this procedure despite ing the following question: when, how, and for which
the availability of new mechanical devices with high population should an IO infusion be used in adults. Fi-
success rate after brief training [6]. Yet, IO access is the nally, a total of 49 records were retained by mutual con-
quickest way to establish access for rapid infusion of sensus, and pertinent data were extracted to prepare
fluids, drugs, and blood products in emergency situa- independent drafts. Once this step had been completed,
tions as well as for cardiac resuscitation [7]. all authors met, reviewed the drafts together, resolved
The aim of this systematic review is to summarize the disagreements by consensus with all the authors, and de-
most relevant information on IO infusion in adults to cided on the final version.
promote its use by physicians working in intensive care
units and emergency departments. Results and Discussion
Historical background and recommendations for IO
Methods access use
A PubMed search for all articles published up to December In 1922, Drinker described the marrow of a mammalian
2015 was performed by using the terms “Intra-osseous” bone as a “non-collapsible vein” [4]. In 1934, Josefson
AND “Adult” (Title/Abstract), which returned 194 records used for the first time an IO access in humans via ster-
(Fig. 1). Retrieval was not limited in time, but only nal location to administer liver concentrate in patients
manuscripts in English or French were selected. Edi- with pernicious anemia [8]. Then, in 1940, Tocantins
torials, comments, and case reports were excluded. and O’Neill described successful administration of blood,
Additional articles were included by using the “related saline solutions and glucose using an IO access in
citations” feature of PubMed. The references of the pediatric patients [9]. IO access was then forgotten by
included articles were reviewed to ensure no relevant physicians and reappeared in the 1980s for children only.
articles had been missed. Finally, the most recent re- It took another two decades before recommendations
views or guidelines on IO or peripheral IV infusion for IO access were included in the 2005 American Heart
were searched. In total, 25 more records were added. Association guidelines for cardiopulmonary resuscitation
Abstracts of the 219 articles that the search yielded and emergency cardiovascular care for adults [10]. Their
were reviewed independently by two authors (FP and last guidelines published in 2015 highlighted the place of
JG) and 135 of them out of scope of this review or IO access when IV access is not readily available in
concerning only children were excluded. The same two adults [5]. Moreover, it is pointed out that IO or IV drug
Fig. 1 Flow diagram of studies selection
