INTRAOSSEOUS

AND ARTERIAL LINE ACCESS

PRESENTER: DR ARVIND QUMAR
SUPERVISOR: DR NARENDERAN
GENERAL OUTLINES

• Indications
• Contraindications
• Equipment
• Procedure
• Complication
• Precaution
ARTERIAL LINE ACCESS
INDICATIONS:
• Arterial blood gases
• Invasive BP monitoring
• Frequent blood taking

CONTRAINDICATIONS:
• Presence or potential limb
ischemia
• Inability to do close
monitoring
EQUIPMENTS

• Local anesthesia
• Alcohol swab
• Needle size 27 G
• Catheter size 24 G
• Heparinized saline
• T-connector
PROCEDURE
1. Check ulnar collateral circulation by modified Allen test
2. Identified the radial pulse (other sites available – PTA, DPA)
3. Topical anesthesia may be applied with occlusive plaster one hour
prior to procedure
4. Clean skin with swab
5. Dorsiflex wrist slightly, puncture the skin and advance catheter in
the same direction as the radial artery at 30-40 degrees angle
6. Advance the catheter 2-3 mm further, when blood appears at the
hub, withdraw the needle while advancing the catheter
7. Ensure good flow, then flush gently with small amount of
heparinized saline
PROCEDURE

9. Ensure line is functioning – the arterial pulsation is usually obvious in the

tubing
10. Connect to T-connector and 3-way stop-clock (red) to syringe pump
11. Label arterial line and time of setting
12. Run heparinizes saline at appropriate rate
- 0.5 – 1 ml/hour for neonates
- 1-3 ml/hour for invasive BP line to avoid backflow in
bigger patients
13. Immobilize joint above and below
 EQUIPMENT
ARTERIAL SAMPLING FROM UAC
• Sterile injection set
• Sterile glove
• Sterile prep
• 3 mL syringes x 2
• 1 ml syringe x 1
• Blood gas syringe x1
• Heparin saline sodium chloride
• Gauze and cotton swabs
VIDEO: UAC/UVC BLOOD TAKING
 PROCEDURE FOR ARTERIAL
SAMPLING
Slowly
Slowly aspirate
aspirate about
about 0.5
0.5 mls
mls (in
(in
Connect 1 ml syringe and preterm babies) to remove
preterm babies) to remove
turn 3-way tap so it is infusate
infusate in
in the
the catheter.
catheter. Keep
Keep
Ensure correct patient closed to clearing infusion and
and maintain sterility of
maintain sterility of sample.
sample.
and open to baby and (This
(This blood
blood will
will be
be returned
returned
syringe when
when sample
sample has
has been
been
obtained)
obtained)

Draw
Draw required
required amount
amount ofof blood.
blood.
Prepare sampling tubes. Bloods
Bloods need to be taken with
need to be taken
Clean bioconnector with with
Check case note to syringe
syringe facing
facing the
the air
air so
so that
that air
air
sterile prep. Allow to dry bubbles rise above. Note
reconfirm blood bubbles rise above. Note
(30 secs) saturations
saturations at
at the
the time
time sample
sample isis
specimens
drawn
drawn

Place paper towel Clear

Clear any
any air
air from
from thethe syringe.
syringe.
Wash hands. Dry hands Reattach the 1 st syringe.
st
Reattach the 1 syringe.
beneath 3-way tap with
with sterile gauze before Always
Always aspirate
aspirate first
first to
to
bioconnector. Maintain remove
putting on sterile gloves remove any
any air
air bubbles
bubbles
asepsis before
before instilling
instilling fluid
fluid
 Attach
Attach syringe
syringe with
with
heparinised
heparinised saline
saline and
and slowly
slowly Update and record the
flush
flush line to clear blood (max
line to clear blood (max 11 Record amount of blood
ml). blood gas results with
ml). Turn
Turn 3-way
3-way tap
tap off
off to
to taken and flush instilled
bioconnector
bioconnector andand on
on to
to baby
baby interpretations
and
and infusion
infusion

Clean bioconnector as
Remove and dispose
before and ensure all
equipment
connections are tightly
appropriately
secured

Recommence
Recommence infusion
infusion pump.
pump.
Ensure
Ensure limbs are
limbs are well
well Transfer
Transfer blood
blood samples
samples into
into
perfused.
perfused. specimen
specimen tubes. Get
tubes. Get an
an
Observe
Observe lower
lower limbs,
limbs, toes
toes and
and assistant
assistant to
to run
run blood
blood gas
gas
abdomen for blanching
abdomen for blanching (for(for immediately
immediately
UAC)
UAC)
COMPLICATIONS

• Arteriospasm
– which may lead to
ischemia and gangrene
• Limb loss
• Sepsis (Eg CLABSI)
PRECAUTION

• Avoid end arteries, e.g. brachial artery and temporal artery

• Test for collateral circulation prior to line insertion
• Circulation chart hourly - color, temperature of the limb, capillary refill time
• DO NOT give medications/fluids via arterial line – can lead to skin necrosis,
severe gangrene and limb ischemia
MANAGEMENT OF DIGITAL AND LIMB
ISCHEMIA

• Remove cannula
• Confirm thrombosis with USG doppler
• Warm affected limb to induce vasodilatation
• Ensure good peripheral circulation and blood pressure
• Consider anticoagulant or thrombolytic drugs
• Refer orthopedic surgeon if gangrene inevitable

* Early detection is very important to prevent irreversible damage

to the limb
 INTRAOSSEOUS ACCESS
Introduction
• A rapid and safe method to establish
vascular access in a critically ill or injured
patient when peripheral or central venous
access is difficult or delayed
• Allows fluids and medications to go directly
into the vascular system
• Non collapsible
• NOT recommended for use longer than 24
hours
 SITES
• Most common site is anterior
tibia (all age group)
• Infants: Distal femur
• Child: ASIS, distal tibia
• Adolescent/adult: Distal tibia,
medial malleolus, ASIS, distal
radius, distal ulnar

1 – 3 cm below and
medial to tibial
tuberosity
INDICATION
• Emergency access for all IV
fluids and medications
when other methods of
vascular access has failed
• IO access may be the initial
means of vascular access in
certain circumstances:
e.g. in severe shock with severe
vasoconstriction or cardiac arrest
CONTRAINDICATIONS

• Fractures, crash injuries near site of insertion

• Conditions in which bone is fragile
• Previous attempts to establish access in the same bone
• Infection of overlying tissues
EQUIPMENT NEEDED

• Sterile dressing set

• EZ-IO drill set, if available
• IO needle
• Syringes for aspiration
• Local anesthesia
 PROCEDURE

1. Immobilize the lower limb and support limb with linen

2. Clean and draped the area
3. Administer LA at the site of insertion
4. Insert the IO needle 1-3 cm below and medial to the tibial tuberosity caudally
5. Advance needle at a 60 to 90º angle
away from the growth plate until a
‘give’ is felt. Remove the needle trocar
stylet

6. Withdraw bone marrow with

5cc syringe to confirm access
7. Infuse small amount of saline and observe for swelling in the insertion site or
posteriorly opposite insertion site
- Fluid should flow in freely
- No swelling should be seen (indicates penetration through posterior cortical
bone) – if seen, remove the needle
8. Connect cannula to tubing and IV fluids
9. Monitor for extravasation of fluids
VIDEO: INFANT CHILD NEEDLE SELECTION AND INSERTION TECHNIQUE
COMPLICATIONS

• Cellulitis
• Osteomyelitis
• Extravasation of fluids/compartment syndrome
• Damage to the growth plate
• Fracture of bone especially in young infant
REFERENCE

• Paediatrics Protocol for Malaysian Hospitals, 4th edition, 2019

• University Hospitals of Leicester NNU Guideline: Arterial line blood sampling