An Update in Adult Intraosseous Infusion


  • Wirot Sombatthavoankun Bangkhla hospital


intraosseous infusion, intraosseous access, IO, intravenous access, IV


The Intraosseous (IO) needle was developed in 1920s to access the vascular system via the bone marrow cavity. Around the 2010s, there was widespread interest in IO after the American Heart Association (AHA) recommended that intraosseous access is an optional route when intravenous (IV) access cannot be obtained quickly. IO had a higher success rate (99.6%), was faster to perform (15-24 seconds), had a nearly equal flow rate (1-5L/hr), and had almost equal drug bioavailability to IV. The complication of IO becoming dislodged was 10-16%, needle dislocation was 0.8%, needle bending was 0.4% and parafusion (defined as fluid leakage at the insertion site causing tissue edema surrounding the leakage point) was 0.4%. Most retrospective trials and meta-analysis studies found that hospital discharge, return of spontaneous circulation (ROSC), and favorable neurological outcome was higher with IV than with the IO group. In conclusion, IO is still beneficial for immediate vascular access and should be placed after and/or simultaneously to IV insertion.

Objectives: to update content of adult intraosseous infusion in critical situations.


Download data is not yet available.


Szarpak L, Ladny JR, Dabrowski M, et al. Comparison of 4 Pediatric Intraosseous Access Devices: A Randomized Simulation Study. Pediatr Emerg Care. 2020;36(10):e568-e572. doi:10.1097/PEC.0000000000001587.

Demir OF, Aydin K, Akay H, Erbil B, Karcioglu O, Gulalp B. Comparison of two intraosseous devices in adult patients in the emergency setting: a pilot study. Eur J Emerg Med. 2016;23(2):137-142. doi:10.1097/MEJ.0000000000000187.

Helm M, Haunstein B, Schlechtriemen T, Ruppert M, Lampl L, Gäßler M. EZ-IO™(®) intraosseous device implementation in German Helicopter Emergency Medical Service. Resuscitation. 2015;88:43-47. doi:10.1016/j.resuscitation.2014.12.015.

Clemency B, Tanaka K, May P, et al. Intravenous vs. intraosseous access and return of spontaneous circulation during out of hospital cardiac arrest. Am J Emerg Med. 2017;35(2):222-226. doi:10.1016/j.ajem.2016.10.052.

Lange P, Umar M, Walker JD, Riddle M, Mochmer P. Evaluation of the NIO™ and T.A.L.O.N Intraosseous Devices as Placed by U.S. Army Conventional Force Combat Medics-A Randomized Crossover Study [published correction appears in Mil Med. 2021 Nov 2;186(11-12):e1257]. Mil Med. 2022;187(7-8):e877-e881. doi:10.1093milmed/usab323.

Rayas EG, Winckler C, Bolleter S, et al. Distalfemur versus humeral or tibial IO, access in adult out of hospital cardiac resuscitation. Resuscitation. 2022;170:11-16. doi:10.1016/j.resuscitation.2021.10.041.

Frascone RJ, Jensen JP, Kaye K, Salzman JG. Consecutive field trials using two different intraosseous devices. Prehosp Emerg Care. 2007;11(2):164-171. doi:10.1080/10903120701205851.

Byars DV, Tsuchitani SN, Erwin E, Anglemyer B, Eastman J. Evaluation of success rate and access time for an adult sternal intraosseous device deployed in the prehospital setting. Prehosp Disaster Med. 2011;26(2):127-129. doi:10.1017/S1049023X11000057.

Tan BKK, Chin YX, Koh ZX, et al. Clinical evaluation of intravenous alone versus intravenous or intraosseous access for treatment of out-of-hospital cardiac arrest. Resuscitation. 2021;159:129-136. doi:10.1016/j.resuscitation.2020.11.019.

Astasio-Picado Á, Cobos-Moreno P, GómezMartín B, Zabala-Baños MDC, Aranda-Martín C. Clinical Management of Intraosseous Access in Adults in Critical Situations for Health Professionals. Healthcare (Basel). 2022;10(2):367. doi:10.3390/healthcare10020367.

Dornhofer P, Kellar JZ. Intraosseous Vascular Access. In: StatPearls. Treasure Island (FL): StatPearls Publishing; June 11, 2022.

Elliott A, Dubé PA, Cossette-Côté A, et al. Intraosseous administration of antidotes - a systematic review. Clin Toxicol (Phila). 2017;55(10):1025-1054. doi:10.1080/15563650.2017.1337122.

Hammer N, Möbius R, Gries A, Hossfeld B, Bechmann I, Bernhard M. Comparison of the Fluid Resuscitation Rate with and without External Pressure Using Two Intraosseous Infusion Systems for Adult Emergencies, the CITRIN (Comparison of InTRaosseous infusion systems in emergency medicINe)-Study. PLoS One. 2015;10(12):e0143726. doi:10.1371/journal.pone.0143726.

Ngo AS, Oh JJ, Chen Y, Yong D, Ong ME. Intraosseous vascular access in adults using the EZ-IO™ in an emergency department. Int J Emerg Med. 2009;2(3):155-160. doi:10.1007/s12245-009-0116-9.

Smith S, Borgkvist B, Kist T, Annelin J, Johnson D, Long R. The effects of sternal intraosseous and intravenous administration of amiodarone in a hypovolemic swine cardiac arrest model. Am J Disaster Med. 2016;11(4):271-277. doi:10.5055/ajdm.2016.0249.

Holloway CM, Jurina CS, Orszag CJ, et al. Effects of humerus intraosseous versus intravenous amiodarone administration in a hypovolemic porcine model. Am J Disaster Med. 2016;11(4):261-269. doi:10.5055/ajdm.2016.0248.

Beaumont LD, Baragchizadeh A, Johnson C, Johnson D. Effects of tibial and humerus intraosseous administration of epinephrine in a cardiac arrest swine model. Am J Disaster Med. 2016;11(4):243-251. doi:10.5055/ajdm.2016.0246.

Hampton K, Wang E, Argame JI, Bateman T, Craig W, Johnson D. The effects of tibial intraosseous versus intravenous amiodarone administration in a hypovolemic cardiac arrest procine model. Am J Disaster Med. 2016;11(4):253-260. doi:10.5055/ajdm.2016.0247.

Miller C, Nardelli P, Hell T, Glodny B, Putzer G, Paal P. Sex differences in appropriate insertion depth for intraosseous access in adults: An exploratory radiologic single-center study [published online ahead of print, 2022 Aug 3]. J Vasc Access. 2022;11297298221115412. doi:10.1177/11297298221115412.

Philbeck TE, Puga TA, Montez DF, Davlantes C, DeNoia EP, Miller LJ. Intraosseous vascular access using the EZ-IO™ can be safely maintained in the adult proximal humerus and proximal tibia for up to 48 h: Report of a clinical study. J Vasc Access. 2022;23(3):339-347. doi:10.1177/1129729821992667.

Jousi M, Laukkanen-Nevala P, Nurmi J. Analysing blood from intraosseous access: a systematic review. Eur J Emerg Med. 2019;26(2):77-85. doi:10.1097/MEJ.0000000000000569.

Tallman CI, Darracq M, Young M. Analysis of intraosseous blood samples using an EPOC point of care analyzer during resuscitation. Am J Emerg Med. 2017;35(3):499-501. doi:10.1016/j.ajem.2016.12.005.

Daya MR, Leroux BG, Dorian P, et al. Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Circulation. 2020;141(3):188-198. doi:10.1161/CIRCULATIONAHA.119.042240.

Feinstein BA, Stubbs BA, Rea T, Kudenchuk PJ. Intraosseous compared to intravenous drug resuscitation in out-of-hospital cardiac arrest. Resuscitation. 2017;117:91-96. doi:10.1016/j.resuscitation.2017.06.014.

Kawano T, Grunau B, Scheuermeyer FX, et al. Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Ann Emerg Med. 2018;71(5):588-596. doi:10.1016/j.annemergmed.2017.11.015.

Hsieh YL, Wu MC, Wolfshohl J, et al. Intraosseous versus intravenous vascular access during cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a systematic review and meta-analysis of observational studies. Scand J Trauma Resusc Emerg Med. 2021;29(1):44. doi:10.1186/s13049-021-00858-6.

Granfeldt A, Avis SR, Lind PC, et al. Intravenous vs. intraosseous administration of drugs during cardiac arrest: A systematic review. Resuscitation. 2020;149:150-157. doi:10.1016/j.resuscitation. 2020.02.025.

Ghazali DA, Fournier E, Breque C, Ragot SP, Oriot D. Immersive simulation training at 6-week intervals for 1 year and multidisciplinary team performance scores: a randomized controlled trial of simulation training for life-threatening pediatric emergencies. Emergencias. 2019;31(6):391-398.

Yauger YJ, Johnson MD, Mark J, et al. Tibial Intraosseous Administration of Epinephrine Is Effective in Restoring Return of Spontaneous Circulation in a Pediatric Normovolemic But Not Hypovolemic Cardiac Arrest Model. Pediatr Emerg Care. 2022;38(4):e1166-e1172. doi:10.1097/PEC.0000000000002127.

El-Nawawy AA, Omar OM, Khalil M. Intraosseous Versus Intravenous Access in Pediatric Septic Shock Patients Admitted to Alexandria University Pediatric Intensive Care Unit. J Trop Pediatr. 2018;64(2):132-140. doi:10.1093/tropej/fmx061.




How to Cite

Sombatthavoankun, W. 2024. An Update in Adult Intraosseous Infusion. Asian Medical Journal and Alternative Medicine. 24, 1 (Apr. 2024), 62–68.



Review Articles