INTRAOSSEOUS INFUSIONS IN INFANTS*
J. T. ELSTON, M.D.,f R. V. JAYNES, M.D.,t D. H. KAUMP, M.D.,
AND W. A. IRWIN, M.D.
From the Departments of Pediatrics, f Pathology and Radiology, Providence
Hospital, Detroit, Michigan
In recent years, increasing attention has been paid to the problem of parenteral
infusions in infants. It appears now that there is not only a constant but a safe
portal of entry in the medullary cavities of the long bones of the legs.
Tocantins 9 discovered that fluids injected into the medullary cavity of bones
in experimental animals entered the general circulation at a very rapid rate.
This principle applied to human infusions proved to have wide application where
intravenous infusion was not practical or possible. 8,10 - 13 Previously, the
danger of dislodgment of fat with production of fat embolism had been ruled
out. 3 ' 5
Since 1941, several articles concerning intraosseous infusion have appeared
in the literature 1 •14 indicating that this manner of infusion in the hands of many
workers is satisfactory, and that the incidence of complications is low.
TECHNIC
Our routine kit for intraosseous infusions is prepared and sterilized in advance,
and contains the following: a Turkel trephine needle; a 2-cc. syringe; a 25gauge needle; a 2-cc. ampule of one per cent procaine solution for local anesthesia; a circumcision drape; a 5-cc. syringe for aspirating the medullary cavity;
and two or three gauze sponges. Alcohol-cleaned glass slides and a paraffin
lined tube containing heparin are kept available for preparation of bone marrow
smears. The hands of the operator are thoroughly washed and rinsed with
alcohol, but rubber gloves are not used.
The site chosen for puncture is the upper one-third of the tibia or the lower
one-third of the femur. Sternal infusion is not practical in children below the
age of 3 to 5 years.11 We prefer the tibia because the bone is directly beneath
the skin and superficial fascia with little or no muscle tissue intervening. A
point is selected approximately one fingerbreadth below the cartilaginous tibial
tubercle and on the flat, superficial, anteromedial surface. This area is
thoroughy cleaned with a suitable topical antiseptic. The circumcison drape
is applied and a wheal is raised in the skin by injection of the local anesthetic.
The subcutaneous tissues and the periosteum are then infiltrated with approximately 1 cc. of the anesthetic solution. The outer needle with stylet in place is
thrust through the skin and subcutaneous tissue and brought into contact with
the bone; slight pressure is exerted to set the needle point in the periosteum.
The needle is directed distally from the epiphyseal line, the stylet removed, and
the rotary trephine inserted. A hole is bored through the cortex by rotary
motion of the trephine. When the trephine enters the medullary cavity, there
* Received for publication, October 11,1946.
143
144
ELSTON, JATNES, KAUMP AND IRWIN
is a sudden drop in resistance. The outer needle is then pushed into the medullary cavity, using the trephine as a guide (Fig. 1).
We do not bind the infant or the infant's leg, but prefer to have the baby flat on
a table with his legs hanging over the edge. The free hand then supports the
tibia or femur, and is used to exert counterpressure when the large outer needle
is inserted into the cavity. An assisting nurse keeps the infant quiet and
comfortable. After the outer needle has entered the medullary cavity, the
trephine is withdrawn and the bone marrow is aspirated. If bone marrow is not
aspirated, the needle is not in proper position, the needle is not entirely through
F I G . 1. D I A G R A M OF A L O N G I T U D I N A L SECTION I N T H E R E G I O N OP THE K N E E J O I N T
I N A P U L L - T E R M , N E W B O R N I N F A N T , SHOWING THE IMPORTANT ANATOMIC
R E L A T I O N S AND T H E C O R R E C T P O S I T I O N OF N E E D L E S FOR I N F U S I O N
I n t h e diagram t h e size of the joint cavity proper is purposely exaggerated
Reprinted from Tocantins, L M., and O'Neill, J . P . : Complications of intraosseous
t h e r a p y , Annals of Surgery, 122: 266-277, 1945, by permission of the J . B . Lippincott
Company.
the cortex, its lumen is obstructed by a spicule of bone, the bevel is in the posterior
cortex, or it has passed through both cortices. If aspiration is not successful,
rotation or gentle withdrawal of the needle may correct the malposition. Infusion is not attempted until bone marrow is aspirated. When bone marrow is
aspirated, the infusion is started quickly in order to prevent clotting of the
aspirated marrow in the needle.
When the transfusion is completed, the needle is rotated slightly to loosen
it from its seat in the cortex and then withdrawn immediately. A sterile pressure
pad is placed over the puncture site and firm pressure maintained for five minutes.
This allows the blood in the defect.to coagulate and form a seal. A sterile
INTRAOSSEOUS INFUSIONS IN INFANTS
145
pressure dressing is applied, but care is taken not to constrict the extremity.
The dressing is removed in forty-eight hours.
We have used two methods of infusing fluids: first, the direct injection with
a two-way stopcock connecting syringe and needle and the infusion flask; and
second, the continuous intraosseous drip. For continuous infusion, the bone
offers a firm emplacement for the needle which is not easily dislodged by the
infant. This constitutes one of the real advantages in using the medullary
cavities for continuous infusion.
Femoral puncture necessitates thrusting the needle through the suprapatellar
bursa and the quadriceps femoris muscle but, otherwise, the technic is similar to
tibial puncture. The site of choice is slightly medial and about two cm. above a
line drawn through the condyles. This site avoids passage of the needle through
the main body of the quadriceps femoris muscle. For continuous drip infusions,
we prefer to use the tibia because the needle and tubing may be attached to the
leg in such a manner that the knee joint does not have to be immobilized. In
femoral puncture, the needle is placed through the quadriceps tendon and may
work loose with flexion and extension of the leg.
In our hands, this technic constitutes a quick and accurate method for bone
marrow puncture. The rotary trephine offers the advantage of requiring
little force, lessens the possibility of going through both cortices, and decreases
the trauma to the periosteum and the bone. There are errors of technic which
should be carefully watched for and guarded against: both cortices may be
pierced; the needle may be so directed that it lodges in the cortex and does not
enter the medullary cavity; the bevel of the needle may be only partly in the
medullary cavity; and if the cortex is comminuted in making the tap, leakage
occurs around the needle subperiosteal^/, or into the subcutaneous tissues
(Fig. 2).
RATE OF FLOW
With direct injection of fluids, the rate of flow in 94 injections varied from 0.6
cc. to 11.0 cc. per minute (average 4.2 cc. per minute) and with continuous drip
in 18 injections, the flow varied from 15 to 40 cc. per hour.
There is apparently little or no discomfort to slow infusions, but if the fluid
is injected under pressure, ^here is definite discomfort which may be due to
increased intramedullary pressure.
REVIEW OF CASES
We have given 112 bone marrow infusions in 40 infants between the ages of
12 hours and 20 months (Table 1). One of these infants weighed three pounds.
Of the 40 infants, 29 are still alive and had no complications. None of the
deaths was attributed either directly or indirectly to intramedullary infusions.
Of the 112 attempts at intraosseous infusion, 97 were successful on the first
attempt. In only one infant, despite two attempts, were we unable to use this
method. In this infant, the cortex was unusually dense. Routinely, anteroposterior and lateral x-rays of the bones were taken one or two days following the
last infusion and again from three to six weeks later.
146
ELSTON, JAYNES, KATTMP AND IRWIN
In most instances, the infusion fluid was whole blood but, when indicated,
we also used 5 and 10 per cent glucose in distilled water and in saline; also
plasma, Hartmann's solution, ascorbic acid, Vitamin B complex, and penicillin.
We have not used solutions of sulfonamides, insulin, antitoxins, or antiserums
which have been given in this manner, 1 •10 but would not hesitate to do so if
the need arose. The amount and type of fluid given were determined by the need
F I G . 2. COMPLICATIONS R E S U L T I N G FROM V A R I O U S E R R O R S I N T E C H N I C OF I N S E R T I N G A
N E E D L E INTO THE M A R R O W C A V I T Y
E a c h drawing represents a sagittal section of t h e manubrium and upper portion of the
body of the sternum of an adult m a n . The same errors are possible when t h e long bones of
t h e legs of infants are used. A, periosteum; B and C, sites of previous recent punctures. 1 1
of the patient. Blood infusions in newborn babies were usually given in amounts
varying from 35 to 50 c c , and were repeated as often as three times a day. Older
infants were given from 50 to 100 c c , depending on their size and need. One
infant was given 1610 cc. of fluids during fifty-eight hours by continuous drip.
Unsatisfactory infusions have been due to several causes. There may be
extravasation of blood through the defect at the site of the former puncture.
INTKAOSSBOUS INFUSIONS IN INFANTS
TABLE 1
SUMMARY OF 112 INTRAVENOUS I N F U S I O N S I N 40 I N F A N T S
NUMBER OF
TAPS
INFANT
NUMBER
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
CLINICAL DIAGNOSIS
METHOD OF
INFUSION
FLUIDS INFUSED
TOTAL
NUMBER OF
CC. I N FUSED
3
CO
13
o
H
<8
3
3
in
0}
COMPLICATIONS
3
d
U
1 1 0
Erythroblastosis fetalis
Erythroblastosis fetalis
Erythroblastosis fetalis
Erythroblastosis fetalis
Erythroblastosis fetalis
Toxic bone marrow depression
Lymphatic leukemia
Bronchopneumonia
Bronchopneumonia, interstitial pneumonitis
Hypoplasia of bile ducts,
obstructive hepatitis
Premature, severe icterus
Erythroblastosis fetalis,
necrosis right lobe of
liver
Premature, intracranial
hemorrhage
Second and first degree
burns
General spasticity, anoxic
encephalopathy
Diarrhea, dehydration
Direct
Direct
Direct
Direct
Direct
Direct
Whole
Whole
Whole
Whole
Whole
Whole
blood
blood
blood
blood
blood
blood
50
375
190
145
330
100
6
5
3
5
2
4
5
3
5
2
2
0
0
0
0
None
None
None
None
None
None
Direct
Direct
Direct
Whole blood
Plasma
Whole blood
25
80
190
1
1
2
1 0
1 0
2 0
None
None
None
Direct
Whole blood
40
1
1 0
None
Direct
Direct
Whole blood
Whole blood
30
58
1
1
1 0
1 0
None
None
Direct
Whole blood
45
3
1
2
None
Direct
Whole blood
370
4
3
1
None
Direct
Whole blood
125
4
3
1
None
Direct
138
1
1 0
None
Diarrhea, anemia eczema
Bronchopneumonia
Erythroblastosis fetalis,
melena
Erythroblastosis fetalis
Celiac disease, toxic bone
marrow depression
Diarrhea
Intussusception
Prematurity
Direct
Direct
Direct
Plasma, 10%
glucose
None
Whole blood
Whole blood
0
55
210
2 0 2
1 1 0
3 3 0
None
None
None
Direct
Direct
Whole blood
Whole blood
235
455
0
9
5
8
3
1
None
None
Direct
Direct
Direct
Whole blood
50
Whole blood
150
Whole blood— 600
Hartmann's
solution 5%
glucose
Whole blood, 3315
Hartmann's
solution, 5
and 10%
glucose,
vitamins
BandC
1
1
6
1 0
1 0
6 0
None
None
None
7
7
0
Subcutaneous
abscess
Diarrhea, marasmus bron- Direct
chopneumonia lung
continabscess
uous
148
ELSTON, JAYNES, KAUMP AND IRWIN
TABLE
I—Continued
NUMBER OF
TAPS
INFANT
NUMBER
CLINICAL DIAGNOSIS
METHOD OF
INFUSION
FLUIDS INFUSED
TOTAL
NUMBER OF
FUSED
3
3
1
H
26
27
Diarrhea
Diarrhea
28
D i a r r h e a , vomiting
29
33
Pneumonia, anemia
(nutritional)
Diarrhea
P r e m a t u r e , vomiting
Erythroblastosis fetalis
with general edema
Diarrhea
34
Diarrhea
35
36
Intestinal obstruction
Post-operative cleft
palate
Bronchopneumonia
30
31
32
37
38
39
40
Feeding problem, polyavitaminosis
Bronchopneumonia mongoloidism
Intracranial hemorrhage
(due t o birth?)
Tot als
Direct
Direct
continuous
Direct
continuous ,
Direct
Direct
Direct
Direct
«
U
3in
=3
O
COMPLICATIONS
50
Whole blood
Whole blood, 990
plasma, 5%
glucose
Whole blood, 260
plasma,
Hartmann's
solution
Whole bloods- 75
saline
40
Whole blood
Whole blood
60
120
Whole blood
1
3
1
3
0
0
None
None
4
3
0
None
1
1
0
None
1
5
2
1
2
2
0
3
0
None
None
None
Direct
continuous
Direct
continuous
Direct
Direct
Plasma, 5%
glucose
220
2
2
0
None
Whole blood,
5% glucose
325
1
1
0
None
Whole blood
Whole blood
50
75
1
1
1
1
0
0
None
None
Direct
continuous
Whole blood,
penicillin,
vitamins
A and B
Whole blood,
saline
Whole blood,
saline
Whole blood,
saline
555
2
2
0
None
260
3
3
0
None
275
4
4
0
None
200
3
3
0
None
Direct
Direct
Direct
112 97 15
This occurs particularly when the infusion is given under pressure. Tocantins
recommended that twenty-four hours be allowed to elapse between infusions in
the same bone, but we have found that twenty-four hours is insufficient time.
When more than one infusion must be given, we have made a routine practice of
rotating the puncture sites, using first one tibia, than the other, followed by one
femur, than the other. In several instances, however, we have infused into
bones where the previous infusion was made less than twenty-four hours before.
INTRAOSSEOUS INFUSIONS IN INFANTS
149
If blood is forced through the site of a former puncture, the infusion should be
stopped and a site in another bone selected. Other failures have occurred due to
the piercing of both cortices with consequent extravasation into the soft tissues.
Defective equipment, such as ill-fitting adapters on the syringes and mis-matched
barrel and plunger, have complicated several infusions to the point where they
were considered unsuccessful.
In the 40 infants in whom 112 bone punctures were made, we have had only
one complication. A summary of this patient's case is presented.
REPORT OF CASE
A 5 week old infant was transferred from t h e nursery to t h e D e p a r t m e n t of Pediatrics,
three weeks before d e a t h , because of severe diarrhea and a low grade fever, both of which
F I G S . 3a AND 3b (From left to right). X - r a y films of the long bones of t h e legs (infant number 1, Table 1) taken six days following t h e last infusion. The changes in
the right tibia were interpreted as traumatic osteitis and periosteitis.
F I G S . 3C AND 3d. Films t a k e n 28 days after t h e last infusion showed nearly
complete resolution of this t r a u m a t i c osteitis and periosteitis without t r e a t m e n t .
had not responded to the usual t r e a t m e n t . T h e infant expired on t h e twenty-fourth hospital day and at necropsy t h e following diagnoses were m a d e : marasmus, bronchopneumonia with abscesses in lower lofcte of right lung, fibrinopurulent pericarditis, chronic colitis
of unknown cause, atrophic gastritis, polyavitaminosis, and subcutaneous abscesses of both
thighs with no bony involvement.
During the hospital s t a y , seven direct or continuous intraosseous infusions were given,
and 170 cc. of whole blood, 310 cc. of plasma, and 2835 cc. of other fluids (total of 3315 cc.)
were t h u s administered.
It was the opinion at necropsy t h a t t h e subcutaneous infection would probably not have
occurred in a less debilitated infant and t h a t , had this infant lived, t h e abscesses would
have been easily managed by simple incision and drainage.
X-RAY STUDIES
In some of our x-ray studies at three days, there was a "traumatic periostitis
and osteitis." These lesions were found on subsequent roentgenograms to
150
ELSTON, JAYNES, KAUMP AND IRWIN
disappear within two or three weeks (Fig. 3). This bony lesion healed in every
instance without treatment and we believe that it does not constitute a real
complication. We have noticed, at the site of puncture, a firm raised nodule
which seems to be attached to the bone. Arbeiter and Greengard1 noted this
also and believed that it represented bone formation at the site of puncture and
could not be called a true complication.
SUMMARY
The need for, and development of, a safe and readily available route of administering fluids into the general circulation of children has been discussed. The
marrow cavities of the long bones of the legs have been used with success. This
method offers a rapid and easily available route of administering fluids, especially
in children where the intravenous route is either impractical or impossible.
Our technic of intraosseous puncture and infusion has been described in detail.
We believe that this technic allows for greater safety and fewer failures than other
technics that have been described.
The incidence of complications in our series and in other series that have been
reported has been very low and in no way should be considered as an objection
to the proper use of this method of infusion.
A summary is given in Table 1 in which 112 intraosseous infusions were attempted in 40 infants. Of these infusions, 97 were successful on the first attempt
and in only one infant were we completely unsuccessful. Our only instance of
complication in this series is reported.
REFERENCES
1. A R B E I T E R , H . I . , AND GREENGARD, J . : Tibial bone marrow infusions in infancy. J .
Pediat., 25:1-12, 1944.
2. B E H R , G . : Bone-marrow infusions for infants. Lancet, 2 : 472^473, 1944.
3. BISGARD, J . D . , AND BAKER, C . : Experimental fat embolism. Am. J . Surg., 47: 466478,1940.
4. D O D D , E . A., AND T Y S E L L , J . E . : Massive intramedullary infusions. J . A. M . A . ,
120:1212-1213, 1942.
5. H A R R I S , R . I . , P E R R E T T , T . S., AND M A C L A C H L I N , A . : F a t embolism.
6.
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110:1095-1114, 1939.
M E O L A , F . : Bone marrow infusions a s routine procedure in children. J . Pediat.,
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3:495-500,1942.
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in pediatrics. Am. J . © i s . Child., 68: 253-256, 1944.
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circulation v i a bone marrow; technique a n d results. Surg. Gynec. a n d Obst., 7 3 :
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TOCANTINS, L. M . , AND O ' N E I L L , J . F . : Complications of intra-osseous t h e r a p y . A n n .
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12. TOCANTINS, L . M . , O ' N E I L L , J . F . , AND J O N E S , H . W . : Infusions of blood a n d o t h e r
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13. TOCANTINS, L . M . , O ' N E I L L , J . F . , AND P R I C E , A. H . : Infusions of blood a n d other
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failure. Ann. Surg., 114: 1085-1092, 1941.
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