Pa Patient Saf Advis 2016 Sep;13(3):81-91.
Complications and Circumstances Pertaining to Intraosseous Lines
Critical Care; Emergency Medicine; Internal Medicine and Subspecialties; Pediatrics
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Lea Anne Gardner, PhD, RN
Senior Patient Safety Analyst
Pennsylvania Patient Safety Authority

Intraosseous Lines

Pennsylvania Patient Safety Authority analysts received an inquiry asking about the type of events that occurred with the use of intraosseous (IO) vascular access catheters and whether events might be related to patient age. IO line access is a method of delivering fluids when a peripheral intravenous (IV) line or central line cannot be obtained in a timely manner, and patient morbidity or mortality is possible.1-6 IO line access was first used in animals in 1922.7 Patient use in a clinical setting was noted in the early 1940s.8 IO access is obtained by inserting a needle through the bone (e.g., proximal tibia, humerus; see Figure 1)9,10 and are generally removed within 24 hours.11,12 The bone provides a non-collapsible cavity to instill fluids and medications, which are absorbed at a similar rate to absorption via peripheral IV lines.7,8

Figure 1. Intraosseous Needle in Tibia

Figure 1. Intraosseous Needle in Tibia Source: Modified from Greene N, Bhananker S, Ramaiah R. Vacsular access, fulid resuscitation, and blood transfusion in pediatric trauma. Int J Crit Illn Inj Sci 2012 Sep;2(3):135-42. 


A variety of guidelines generally based on age identify the appropriate circumstances for implementing this type of line access.2-5,13 For example, the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science recommend the use of IO access in children and adults if venous access is not readily available during an emergency.5,12 Contraindications for an IO insertion include ipsilateral (i.e., same side) fractures, previous attempts at ipsilateral IO access, local vascular injuries, cellulitis, infection or injury to the skin around the site, and burns.14,15 Intraosseous insertion should be also avoided in patients with a high risk for fractures (e.g., severe or advanced osteoporosis, osteogenesis imperfecta).13,14

Authority analysts queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) to identify events related to IO lines during the most recent 10-year time period, January 1, 2006, through December 31, 2015, by using the keywords “IO,” “i.o.,” “i-o,” “intraos,” and “interos.” The query identified 175 event reports; 85 were excluded because they were irrelevant to the scope of the query (e.g., IO as an abbreviation for intraocular) or addressed a non-IO line event (e.g., fall) during which the patient had an IO line present. The remaining 51.4% (n = 90 of 175) event reports addressed IO clinical (e.g., insertion site complications) or system matters (e.g., equipment availability or breakage).

The first part of the analysis examined the occurrence of harm and patient age. Five of the 90 event reports (5.6%) resulted in harm reaching the patient.* Slightly more than one third 34.4% (n = 31 of 90) event reports occurred in children younger than 10 years of age. Figure 2 provides the distribution of event reports by patient age (i.e., newborn to 23 months old and newborn through 99 years old) by harm score.

Figure 2. PA-PSRS Intraosseous Access Event Reports by Patient Age and Harm Score Heat Map, January 2006 through December 2015 (N = 90)*

Figure 2. PA-PSRS Intraosseous Access Event Reports by Patient Age and Harm Score Heat Map, January 2006 through December 2015

* There were no event reports for children age 4, 10, 13, and 15 to 23 months.


All of the IO events were reported by hospitals, and analysts grouped them according to the type of care area. The list below shows the hospital location where the events were reported. 

  • Intensive care units (40.0%, n = 36 of 90)
  • Emergency departments (36.7%, n = 33)
  • Medical, surgical, or pediatric units (13.3%, n = 12)
  • Intermediate medical, surgical, or pediatric units (5.6%, n = 5)
  • Unit location not identified (2.2%, n = 2)
  • Imaging (2.2%, n = 2)

An analysis of the event narratives identified 15 clinical conditions or system matters involving an IO line. Of the 90 event reports, 41.1% (n = 37) described two or more circumstances in the event narrative. For example, in four events, the plastic hub disconnected from the metal IO needle during removal and in each instance, a hemostat or plier was used to remove the needle from the patient’s bone. See Figure 3 for the  clinical conditions and system matters and their numbers of events.

Figure 3. PA-PSRS Intraosseous Line Clinical Conditions and System Matters, January 1, 2006, through December 31, 2015 (N = 90)*

Figure 3. PA-PSRS Intraosseous Line Clinical Conditions and System Matters, January 1, 2006, through December 31, 2015 (N = 90) * 41.1% (37 of 90) of the event reports had two or more circumstances identified in the event narrative. 


The following selected PA-PSRS event narratives provide clarity about the circumstances associated with the IO events reports:

Extravasation and Pain

Registered nurse noticed that patient’s IO [site] was cold and appeared to be infiltrated. Patient complained of severe pain where IO was placed. Swelling around IO site. Warm compress applied, pain meds given.

Extremity and Extravasation 

Patient’s lower extremity noted to be swollen and cool. IV assessment prior to infiltration noted site ok… Infusions stopped, IO removed, extremity elevated, warmed packs applied.


The patient coded and there was no IV access. There was no IO needle in the code cart so nurses had to go to another floor to obtain one.

Removal, Needle, and Equipment 

Peripheral access had been obtained. Attempted removal of intraosseous (IO) line, unable to remove. During attempts to unscrew IO device, plastic attachment device came off leaving only the needle in the patient’s leg. After multiple attempts the needle was removed and found to be slightly bent.

In Pennsylvania, IO needles can be inserted by physicians, advanced emergency medical technicians, and paramedics.16 Regarding nurses, the Pennsylvania nurses’ scope of practice does not prohibit the insertion of an IO line;17 nevertheless, it is advisable for nurses to follow facility policies for  inserting and accessing these lines.

The literature shows that use of IO lines is limited by lack of equipment and training.18 Training in proper insertion techniques is available through Advanced Trauma Life Support and Pediatric Advanced Life Support courses.19 The type of device used and training have been shown to increase insertion success rates.20-22 The American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care identified multiple case studies showing that providers with different levels of training could rapidly establish IO access with minimal complications for children in cardiac arrest.3,12

Although the overall number of events reported is small, the proportion involving young children is worth noting. It is unclear whether the larger number of IO event reports involving children reflects a greater risk of complications for each IO insertion or whether there may be a larger number of IO insertions in very young, ill children, in whom starting an IV may be particularly difficult. The risk of IO insertion is to be balanced against the risks of IV insertion and the risks of untimely vascular access. Training, education, and resource availability can help with successful insertion of IO lines.

 The Pennsylvania Patient Safety Authority Harm Score Taxonomy is available online at;12(1)/PublishingIMages/taxonomy.pdf


  1. American College of Emergency Physicians. Policy statement: Alternative methods to vascular access in the emergency department [online] 2014. [cited 2016 Jun 28]  
  2. Emergency Nurses Association Clinical practice guideline: difficult intravenous access [online]. 2015 [cited 2016 Jun 28].  
  3. Kleinman ME, de Caen AR, Chameides L, et al. on behalf of the Pediatric Basic and Advanced Life Support Chapter Collaborators. Part 10: Pediatric basic and advanced life support: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations [online]. 2010 Nov 2 [cited 2016 Jun 28].
  4. Perlman JM, Wyllie J, Kattwinkel J, et al. Part 11: Neonatal Resuscitation: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations [online]. 2010 Nov 2 [cited 2016 Jun 28].
  5. Neumar RW, Otto CW, Link M, et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science: Part 8 Adult advanced cardiovascular life support [online]. 2010 [cited 2016 Jun 28].  
  6. Consortium on intraosseous vascular access in healthcare practice. Recommendations for the use of intraosseous vascular access for emergent and nonemergent situations in various health care settings: a consensus paper [online]. 2010 Nov/Dec. [cited 2016 Jun 28].  
  7. Drinker CK, Drinker KR, Lund CC. The circulation in the mammalian bone-marrow [online] 1922. [cited 2016 Jun 28] at:
  8. Papper EM. Bone marrow route for injecting fluids and drugs into the general circulation [online]. 1942 [cited 2016 Jun 28].  
  9. Paxton JH. Intraosseous vascular access: a review online. 2012 Jan 3 [cited 2016 Jul 13].  
  10. Dev SP, Stefan RA, Saun T, et al. Insertion of an intraosseous needle in adults [online]. 2014 Jun 12 [cited 2016 Aug 1].  
  11. Leidel BA, Kirchoff C, Bogner V, et al. Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins. Resuscitation 2012;83:40-5.
  12. INS Position Paper. The role of the registered nurse in the insertion of intraosseous access devices. J of Infus Nurs 2009 Jul/Aug 32(4):187-8.
  13. Kleinman ME, Chameides L, Schexnayder S, et al. Part 14: Pediatric advanced life support: 2010 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science [online]. 2010 Nov 2. [cited 2016 Jun 28].
  14. Tobias JD, Ross AK. Intraosseous infusions: a review for the anesthesiologist with a focus on pediatric use. Anesth Analg 2010;110:391-401.
  15. Anson JA. Vascular access in resuscitation: is there a role for the intraosseous route? [online]. 2014 Apr [cited 2016 Jul 1]. 
  16. Pennsylvania Bulletin Notice. Scope of practice for emergency medical service providers; update to 2014 Notice [45 Pa.B. 377] [online]. 2015, Jan 17 [cited 2016 Jun 29] at:  
  17. Pennsylvania Chapter 21. State Board of Nursing [online]. 2010 [cited 2016 Jun 30].  
  18. Hallas P, Brabrand M, Folkestad L. Reasons for not using intraosseous access in critical illness. Emerg Med J 2012 Jun;29(6):506-7.
  19. Smith R, Davis N, Bouamra O, et al. The utilization of intraosseous infusion in the resuscitation of paediatric major trauma patients. Int J Care Injured 2005;36:1034-8.
  20. Oriot D, Darrieux E, Boureau-Voultoury A, et al. Validation of a performance assessment scale for simulated intraosseous access. Simul Healthc 2012;7(3):171-5.
  21. Levitan RM, Bortle CD, Snyder TA, et al. Use of battery-operated needle driver for intraosseous access by novice users: skill acquisition with cadavers. Ann Emerg Med 2009;54(5):692-4.
  22. Gazin N, Auger H, Jabre P, et al. Efficacy and safety of the EZ-IO intraosseous device: out-of-hospital implementation of a management algorithm for difficult vascular access. Resuscitation 2011;82:126-9. 

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