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The scene. It's 2 a.m. in a crowded emergency department and you get a standby call of a two year old coming in with severe DKA. When they arrive, they are drowsy and you try several times for an IV line but you're unsuccessful. The child is shocked and needs a fluid bolus urgently and you're not sure that senior help will be any more successful than you have been. What can you do? An IO needle may be the answer. Many doctors shy away from this procedure mostly through fear and unfamiliarity. But in this video, we will learn how to make IO needles your friend. Doctor Matthew Sayers, a consultant, pediatrician with over 10 years experience in pediatrics. And I have put in a number of IO needles with varying degrees of success. In this video. I will share my experience and tips from successful and unsuccessful procedures. Links to all guidelines and documents in this video are available on the A medical app and also in the video description, intraosseous needles work by accessing a highly vascular bone marrow and giving medications into the central circulation. Through this. Any fluid blood product or resuscitative medication can be given and flow rates of 60 to 100 mils per minute can be used in what situations would IO needles be recommended in cardiac arrest? IO needles are the recommended first line method and this is due to the very low likelihood of being able to achieve IV access more rapidly than IO access in other life threatening situations in which fluids, medications or blood products are required urgently. For example, sepsis, shock or refractory seizures. IO access should be performed if uh a few attempts at IV access are unsuccessful because IO needle is an emergency procedure. There are no absolute contraindications to using it. However, if the child has a significant disorder such as osteogenesis and perfecta, this should be avoided if possible. There are specific contraindications on a bone by bone basis for Children. So if there are signs of superficial skin infection, a previous attempt in that bone or no one fracture or vascular abnormality, io this should not be attempted in that bone, but it can be attempted in another bone that does not have these country, make sure you size each iron needle appropriately. Whilst iron needles are traditionally sized on weight. Uh the more important factor is the amount of subcutaneous fat between the bone and the skin. Uh as a rule of thumb, use a pink needle for Children less than six months. A blue for greater than six months and a yellow for Children with significant obesity or teenagers assemble your equipment. You will need io needles, an IO drill, an IO securing set and an IO extension connector. A sanitizing wipe and a flush 2% lidocaine should also be available to reduce the post procedure. Identify your landmark for insertion. The distal tibia is generally preferred, palpate the tibial tuberosity. Your insertion site will be one figure bre medially if the tibial tuberosity is not palpable, palpate the inferior border of the patella and go two finger breadths down and one finger breadth medially to this clean the insertion area and allow it to dry, feel for a flat area of bone and pinch the bone on either side to prevent movement. Insert the tip of the IO needle through the skin and advance until it touches the bone. Ensure that the top five millimeters of the black marker are visible on the IO needle to ensure there is adequate insertion length, ensure that you secure the child's leg by firmly gripping the anterior surface of the shin, do not encircle the limb behind the area in which the needle is inserted. In case it accidentally comes out the other side, carefully drill into the bone with the io needle and drill at a 90 degree angle to the bone. Let the drill do the work and don't apply excess pressure. A gave should be felt and the needle should advance easily, remove the drill and unscrew the top of the IO needle, a small amount of bone marrow can be aspirated and the needle should flush, easily, attach the io securing set over it to secure it in place and then attach the extension set flush to ensure it is still in situ. If the proximal tibia is not suitable, there are some alternative sites, distal tibia palpate the medial malleolus and feel two finger breadths approximately feel for the flat part of the bone in the middle of the tibia. Distal femur palpate the superior aspect of the patella in the midline and go one finger breadth above and one finger breadth medially aim around 15 degrees towards the head to avoid hitting the growth plate, proximal humerus. This is more useful for older Children and a larger needle may be required as there is more subcutaneous tissue in this area place the child's hand on their umbilicus and palpate the anterior aspect of the proximal humerus until you feel a prominence which is a greater tuberosity. Your insertion landmark is one centimeter proximal to this. It is important to provide lots of reassurance to the child and parents before during and after the procedure. If the child is conscious and infusing fluid is painful, a small volume of 1 to 2 mils of 2%. Lidocaine can be slowly infused through the IO over around two minutes left for one minute and then slowly flushed with saline. What are the complications of IO needles? IO needles are generally extremely successful with the 92% success rate but there is a relatively high 21% complication rate. The most common complication of iron needles is extravasation and this generally happens when the IO needle is not um inserted sufficiently into the bone dermal abrasion is also common with io needles. And this is caused by the plastic casing of the IO needle rubbing against the skin with the drill rotating. This is generally quite minor, more serious but very rare complications of IO. Needles are osteomyelitis, significant fracture and fat embolism. Always watch out for compartment syndrome in which the leg is very swollen and very painful. This is more common in infants. So we take particular care with these patients. Io needles can be used in neonates and small babies. But there's a lower success rate and a higher complication rate. The mean medullary diameter of the neonates, proximal tibia is approximately seven millimeters and the smallest IO needle, a pink is 15 millimeters in length. This means that you cannot insert the IO needle all the way to the skin and you'll need to stop before that. This can make securing knees very difficult and make sure they are well taped down. Uh always monitor the baby's leg closely for extravasation and compartment syndrome and try and remove the iron needle as soon as possible. Once IV access has been obtained, an IO needle can remain in place for up to 24 hours to remove it, take off the dressing and extension set and attach a lure lock syringe, rotate clockwise and gently pull until the IO comes out, apply a dressing over the insertion site. Thanks so much for watching. Please like this video. Comment with any clinical questions or feedback you have and subscribe to the channel and our other social media accounts including Instagram, Twitter, Med All and Ola to stay up to date with future videos. I look forward to seeing you again soon.