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Cannot cannulate: bonulate!

Weiss, Markus; Engelhardt, Thomas

European Journal of Anaesthesiology: June 2012 - Volume 29 - Issue 6 - p 257–258
doi: 10.1097/EJA.0b013e3283545a32

From the Department of Anaesthesia, University Children's Hospital, Zurich, Switzerland (MW); Department of Anaesthesia, Royal Aberdeen Children's Hospital, Aberdeen, UK (TE)

Correspondence to Markus Weiss, MD, PhD, Department of Anaesthesia, University Children's Hospital, Steinwiessstrasse 75, CH 8032 Zurich, SwitzerlandTel: +41 44 266 71 11; fax: +41 44 266 80 32; e-mail:

Difficult or failed peripheral venous cannulation in children presents a constant challenge for the clinician. Alternative routes, such as intramuscular, tracheal or intra-arterial, cannot always deliver the appropriate treatment and have their own life-threatening complications as well as failures. This problem is not unique to junior staff but affects even the most experienced paediatric anaesthesiologists. However, due to their own professional belief and pride, the latter think that they can succeed when others have failed. This belief comes from years of experience with daily practice of cannulating children. However, even the best can fail, especially in the very small and/or very sick child.1

When percutaneous cannulation fails, the only alternative technique for vascular access is the intraosseous route, which has proved to be a very reliable technique, especially in urgent situations, and is easy to learn. It permits intravenous (i.v.) infusion via the vasculature of the bones. One advantage is that, compared to peripheral veins, the bone marrow vessels will not collapse in shock or hypothermia.2 The technique has a very low morbidity and no mortality and allows administration of all i.v. fluids and drugs with identical doses and kinetics to the percutaneous route.

Intraosseous infusion was popular more than 50 years ago, before the introduction of indwelling plastic cannulae. Intraosseous needles were inserted routinely in hundreds of children and had a very low reported complication rate. However, they were subsequently considered obsolete and replaced by a variety of plastic cannulae, surgical access or ‘cut-down’ techniques.

‘A kingdom for an intravenous line’: this plea from an editorial by Orlowski2 was written shortly after another disastrous inhalational anaesthesia event in a child without i.v. access.3 It highlighted the potential of intraosseous access in children requiring instant drug and/or fluid resuscitation. Subsequently, the European Resuscitation Council (ERC) and the American Heart Association adopted this as a standard in paediatric emergency care. Since 1994, the ERC has recommended the insertion of an intraosseous needle after 90–120 s or two to three failed attempts at peripheral cannulation.4

Despite the establishment of intraosseous access as a standard technique for alternative vascular access in paediatric emergency medicine, leading paediatric anaesthesiologists have continued to recommend perseverance with multiple user attempts at peripheral/central venous cannulation, intra-arterial or other routes in children requiring urgent vascular access.5–7 Regardless of a considerable burden of evidence in support, intraosseous infusions were not recommended. Essentially, concerns about rare and nonlethal risks of intraosseous access were considered more important than severe hypoxia, hypotension and even cardiac arrest.5,8,9 Although intraosseous access is mentioned as an alternative to i.v. access in some paediatric anaesthesia textbooks,10 its use has still not gained wide acceptance in paediatric anaesthesia and is only considered in the ‘small print’.

Anaesthesiologists are frequently involved in prehospital paediatric emergency care in central Europe, and intraosseous access has been included in paediatric anaesthesia training, teaching and clinical practice.11,12 In addition, the elective use of intraosseous needles in children with failed venous access under inhalational anaesthesia has now been reported by several centres13 and is thought to be less traumatic and dangerous than central venous cannulation in the MRI suite or in a day case setting.

In the meantime, better and more suitable paediatric intraosseous equipment has also become available. Technical difficulties and complications from semiautomatic or fully automatic systems appear to be very small when compared with manual intraosseous systems, with a success rate approaching 100% for first or second attempts.14–16

Several specialist paediatric anaesthetic societies are currently working on clinical recommendations for the immediate availability of intraosseous access equipment wherever children are anaesthetised. The Scientific Workgroup of German Paediatric Anaesthetists has published their first recommendations for the use of intraosseous access in paediatric anaesthesia with clearly defined indications for intraosseous puncture in paediatric anaesthesia care17 (Table 1).

Table 1

Table 1

The place of intraosseous access in urgent situations following failed attempts at percutaneous cannulation is accepted. The time taken and number of failed peripheral i.v. cannulation attempts before semielective intraosseous access is indicated remain open to debate.

It is important to stress that recommendations for the use of intraosseous access will need to be adapted locally and should address the general availability, education and training of all clinicians involved in paediatric anaesthesia. Parental consent and information for the potential use of intraosseous access in expected and unexpected cases will need to be dealt with during the preoperative visit.

These recommendations are not only offered as a ‘help’ or ‘support’ for anaesthesiologsts in a situation with extremely difficult or impossible venous access; they exist to highlight the adoption of the intraosseous route as the approach of choice in a child requiring urgent vascular access.17–19 Intraosseous access following multiple failed venous puncture attempts in anaesthetised children may become imperative to prevent cardio-respiratory deterioration, unacceptable delays and, finally, medico-legal problems.

Although intraosseous access appears to be a simple, easy to learn, highly successful and reliable technique, complications can occur. Mechanical problems such as fractures, broken or bent needles and transosseous perforation should be reduced or eliminated with modern intraosseous infusion systems. Osteomyelitis may occur, particularly following the use of hypertonic solutions (glucose and sodium bicarbonate), nonsterile emergency puncture, incorrect use of syringes or three-way taps, and in children with septicaemia in whom the intraosseous needle is left in place for several hours.20–22 In common with all practical techniques, time must be found for daily routine practice to optimise chances of a successful venous puncture. Intraosseous access should only be reserved for patients who are at risk of hypoxia secondary to functional airway obstructions and aspiration, hypovolaemia, hypothermia, cardiovascular instability or when the insertion of a central venous catheter is considered a higher risk or is not justified. Resources and training will need to be allocated in order to ensure minimal risk for intraosseous access and maximum success for its use.

Life as a paediatric anaesthetist is difficult enough, especially for those who practice this only occasionally. If faced with the impossible peripheral i.v. cannulation we should never forget the bones: cannot cannulate: bonulate!

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This article was checked and accepted by the Editors, but was not sent for external peer-review.

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