Iowa Neonatology Fellows
Peer Review Status: Internally Peer Reviewed


In critically ill infants, placement of intravenous catheters is often difficult and time consuming. The intraosseous route offers immediate vascular access required for emergency administration of drugs during resuscitation. Intraosseous infusion uses the rich vascular network of long bones to transport fluids and drugs from the medullary cavity to the circulation. The response and distribution of fluid and drugs injected via the intraosseous route appears to be very similar to that after intravenous injection. The procedure should be limited to emergencies in which intravenous access (including umbilical vein catheterization) cannot be established in a reasonable length of time, usually 2-5 minutes.


  • Insertion of a needle into the medullary cavity of a long bone should be rapid and simple. 
  • In infants less than 12 months of age, a 16- or 18-gauge spinal needle with a stylet is recommended. 
  • The preferred site is the medial proximal tibia because of its broad flat surface and thin layer of skin covering the bone. 
  • A point is selected 1 to 2 cm below the tibial tuberosity on the medial flat surface of the anterior tibia. 
  • The needle is directed at an angle of 60 degrees pointing away from the joint space and growth plate with a screwing motion. 
  • Entry into the marrow space is noted by a decrease in resistance. The distance from the skin through the bony cortex is rarely more the 1 cm. A common mistake is to advance the needle into or through the opposite side of the bone. 
  • To confirm placement, a saline filled syringe is attached to the catheter and infused slowly while palpating the limb for extravasation. 
  • Drugs may be administered rapidly or by slow infusion. 
  • Conventional vascular access should be established with discontinuation of the intraosseous infusion as soon as reasonably possible. 


  • Success rate is about 80%. 
  • The most common complication is subcutaneous or subperiosteal infiltration of fluid. 
  • Risks of cellulitis and osteomyelitis are less than 1% and related to duration of catheter placement. 
  • No lasting negative effects on growth plate development have been reported.