ADVANCED VASCULLAR

ACCESS–INTRAOSSEUS
dr. M. Arief Kurniawan,SpAn
SMF Anestesi dan Terapi Intensif RSUD Cibinong
 Case
• a 5-year-old boy comes to the
emergency room with severe
dehydration. somnolence awareness,
blood pressure is not measured, pulse
is not palpable
• 25-year-old woman experiencing
postpartum bleeding. blood pressure
is not measured, the pulse is not
palpable
APA ITU AKSES
INTRAVENA??
• Akses intravena/intravenous access
Intravenous (IV) cannulation is a
technique in which a cannula is placed
inside a vein to provide venous
access. Venous access allows sampling of
blood, as well as administration of fluids,
medications, parenteral nutrition,
chemotherapy, and blood products

• Merupakan teknik untuk memasang

kanul/kateter ke dalam pembuluh darah
vena sebagai akses untuk memberikan
cairan, obat, nutrisi, produk darah dan
pengambilan sample darah.
 • Obsesitas
• Dehidrasi/hipovolemik
• Pembuluh darah vena
kecil atau tidak teraba
• Sudah dicoba hampir
semua tempat/site oleh
nakes lain/rs lain
• Memerlukan akses
untuk volume atau
konsentrasi besar
Problem dalam pemasangan
akses intravena
• Difficult intravenous access is defined
as requiring multiple attempts and/or
the anticipation of needing special
interventions to establish and
maintain peripheral venous access
(Kuensting, DeBoer, Holleran, Shultz, Steinmann, & Venella, 2009)

• Difficult peripheral intravenous

cannulation (DPIVC) occurs in 10%–
24% of adults and in up to 37% of
children who require a peripheral
route during hospital
(Rodriguez-Calero MA, et al. BMJ Open 2018;8:e020420.
doi:10.1136/bmjopen-2017-020420)
• Indikasi & kontraindikasi
pemasangan akses vena
• Teknik pemilihan site/tempat akses
vena
• Teknik advanced akses vena
• Vein viewer
• Landmark guided
• USG guided
• Teknik perawatan akses vena
• Teknik intraosseus vascular access
• Vena seksi
SKDI
USG Guided
vein access
 BASIC PRINCIPLES
• Audible sound–20 Hz to 20,000 Hz
• Ultrasound >20,000 KHz
• Medical Ultrasound – 1.0 MHz to > 15MHz
• Piezo electric crystals used to generate ultrasound
Modes of Ultrasound

# A-mode (amplitude mode)

a single transducer scans a line through the body with the echoes plotted on screen as a function
of depth.

# B-mode (brightness mode)

Linear array of transducers simultaneously scans a plane through the body. View as 2D

# M-mode (motion mode)

Pulses emitted in quick succession. Can be used to determine the velocity of organ structures

# Doppler mode
Makes use of Doppler effect and visualizing blood flow
A-mode

B-mode

M-mode Doppler-mode
Speed of Sound
• Speed of sound various among different tissues
• Transmission of ultrasound waves in human tissues : 1540 m/s
Wavelength and Frequency
• Inversely related
• Lower frequency à better penetration but less resolution
• Higher frequency à better resolution but less penetration
Echogenicity
• Anechoic : no echoes are reflected back to transducer
• Hypoechoic : only little echoes are reflected
• Hyperechoic : most echoes are reflected back
 KNOBOLOGY
The functionality of controls on an instrument as relevant to
their application
# Probe selection
# Depth
# Focus
# Gain
# Doppler
# Capture / record
Probe Selection
• Most important decision
• High frequency is best for superficial structures
• Choosing inappropriately low frequency will result in poor resolution
• However, deep structures require lower frequency due to attenuation
• High frequency : depth within 3-4 cm
• Low frequency : depth greater than 3-4 cm
• High frequency = 8-12 MHz
• Medium frequency = 6-10 Mhz
• Low frequency = 2-5 MHz
Which probe do I need?

Probe selection is always a trade off between axial resolution VS depth of

penetration

High frequency probe : better axial and lateral resolution Low frequency probe :

deeper tissue penetration

Area leher:
- jugular
eksterna
- jugular
interna
SHORT AXIS
LONG AXIS
INTRAOSSEUS ACCESS
• Intraosseous infusion is the
process of injecting directly into
the marrow of a bone. This
provides a non-collapsible entry
point into the systemic venous
system. This technique is used to
provide fluids and medication
when intravenous access is not
available or not feasible
 Recent
Bone Marrorw
Gun
World War 2
The IO route was
later used by
military medical
1920 personnel

the sternum was

described as a
potential site for
transfusions
ANATOMY
• Within the epiphysis (proximal and distal
end) of the medullary space of the bone lies
a vast system of blood vessels and sinusoids,
the Haversian canals and Volkmann canals,
which function as rigid non-collapsible
canals. During IO infusion to this large
network, blood and fluid travel quickly
through this component of the vascular
system out nutrient and emissary vessels to
reach the central circulation.
 Theoretically, intraosseous access can be obtained in any large bone and current
devices support several specific points of access, including the sternum.

VENOUS As bones are non-compressible, the intraosseous space will stay patent, even in
shocked patients. This provides a readily available route for infusion of drugs or
fluids in an emergency, while also providing access to bone marrow aspirate,
BLOOD which can be used for some simple blood tests.

DRAINAGE The venous plexus of long bones has been shown to drain in to the central

FROM BONES circulation, at a rate comparable to central venous access.

Fluid resuscitation can also be accomplished via the IO route, with respectable
flow rates of 1-3L/hour via tibial access or 5L/hour via humeral access. Due to
the intrinsic pressure of the intraosseous space, infusions commonly do not flow
effectively with gravity alone and need to be administered under pressure e.g.
using pressure bags, syringe driver or manual flushing.
 INDICATIONS

• There are numerous conditions

where IV access may be difficult
and this can be overcome by using
the intraosseous route. All forms of
physiological shock, hypothermia,
multiple previous intravenous
lines, or intravenous drug use are
common situations where IO
access has proven invaluable
CONTRAINDICATIONS
• Absolute
• Bone trauma at or proximal to the insertion site, or previous IO insertion
in the same limb: disruption of the bone at or proximal to the site allows for
extravasation of infusions and potentially the development of compartment
syndrome.
• Infection overlying the point of insertion: there are concerns of seeding the
infection into the bone and causing osteomyelitis
• Relative
• Prosthesis in the target limb (knee replacement, tibial nail, humeral plate),
or previous sternotomy: the disruption of the bone matrix can
unpredictably interfere with insertion or flow rates and insertion into in-
dwelling metal work could potentially cause damage to the prosthesis or IO
needle.
• Difficulty in identifying anatomical landmarks: in these patients, IO devices
should be deployed with extreme caution, as damage could be caused to
other underlying structures
ACCESS SITES
GENERAL ADVICE FOR
ESTABLISHING IO ACCESS
In all IO access attempts, the following key points should be followed:
1. Sterilisation of the skin at the needle insertion site
2. Manual stabilisation of the bone during insertion
3. Aspiration after needle insertion confirms successful placement
4. In the awake patient, injection of local anaesthetic (preferably
lidocaine) into the IO needle prior to use can reduce pain for
subsequent infusions
5. Ensure the needle is flushed with at least 10ml of fluid after drug
administration
6. Clear documentation of the procedure in the patient notes
7. Frequent assessment of the IO site for signs of extravasation
TYPES OF DEVICES
Manual trocar
• Powerful, for paediatric patients for lower limb access sites.
• The simplicity of the device and lower cost.

Spring loaded devices

• spring-loaded system to assist penetration into the medullary canal.
• Single use

Drill based devices

• battery powered and allow easier placement in a wide variety of access sites.
• Easy
EQUIPMENT
• Alcohol swabs
• 18G needle with trochar (at least 1.5 cm in length)
• 5 ml syringe
• 20 ml syringe
• Infusion fluid
TECHNIQUE
• Identify the appropriate site
• Proximal tibia: Anteromedial surface, 2-3 cm below the tibial
tuberosity
• Distal tibia: Proximal to the medial malleolus
• Distal femur: Midline, 2-3 cm above the external condyle
• Prepare the skin
• Insert the needle through the skin, and then with a screwing
motion perpendicularly / slightly away from the physeal plate
into the bone. There is a give as the marrow cavity is entered
• Remove the trocar and confirm position by aspirating bone
marrow through a 5 ml syringe.
• Marrow cannot always be aspirated but it should flush easily.
• Secure the needle and start the infusion (this needs to be
manually administered as boluses with the 20 ml syringe
 EXTRAVASATION COMPARTMENT OSTEOMYELITIS RISK OF DAMAGE TO
SYNDROME. UNDERLYING
STRUCTURES, WITH
REPORTS OF TIBIAL

COMPLICATIONS FRACTURES IN
PAEDIATRIC PATIENTS.

PNEUMOTHORAX, EPIPHYSEAL DAMAGE BONE MARROW

DAMAGE TO THE EMBOLI ON INSERTION
GREAT VESSELS AND
MEDIASTINITIS.