Interosseous Access for the Neonate in Need

Interosseous Access for the Neonate in Need

The neonate in shock strikes fear into even the most veteran physicians (and certainly makes my brain slip a gear or three). Part of the reason is that it happens relatively infrequently (why simulation training is helpful); however, another reason is that many times this critically ill patient is difficult to get IV access on. They have small vessels, under a relatively large amount of subQ tissue, and they are often profoundly dehydrated.


  • Umbilical Vein – Emergent (not prolonged) access
    • Recall that the recently born comes with ready-made central access.
    • The umbilical vein can be used up to ~2 weeks of age.
    • The location of the cord clamp will affect your decision.
    • It is not a difficult procedure… but does take planning and practice. (see video on Blog for instructions).
  • Interosseous Line – yes, even in neonates and newborns!
    • May be used in any age patient (newborn to elderly).
    • May be quicker and more easily performed than umbilical vein catheterization.
    • The marrow space functions as a non-collapsible vein.
    • Absorption from the medullary cavity to the systemic circulation is rapid (although slower than intravenous).
    • Tibia and Femur are the preferred sites because of their well developed marrow cavity, even in neonatal period.
    • Even after obtaining interosseous access, peripheral or central access should still be obtained as the interosseous route has a slower rate of infusion and, therefore, cannot reverse hypovolemic shock easily.
    • All pediatric resuscitation drugs may be given through IO.
    • Blood aspirated from IO may be used for electrolytes, glucose, BUN/creatinine and blood type and cross-match.
      • A CBC will be erroneous.

Hodge, D., Intraosseous Infusion, in Textbook of Pediatric Emergency Procedures, 2nd Edition, C. King and F.M. Henretig, Editors. 2008, Lippincott Williams & Wilkins. p. 281-288.
Ellemunter, H., et al., Intraosseous lines in preterm and full term neonates. Arch Dis Child Fetal Neonatal Ed, 1999. 80(1): p. F74-5.
Abe, K.K., G.T. Blum, and L.G. Yamamoto, Intraosseous is faster and easier than umbilical venous catheterization in newborn emergency vascular access models. Am J Emerg Med, 2000. 18(2): p. 126-9.
Garro, A.C. and J.G. Linakis, Umbilical Vessel Catheterization, in Textbook of Pediatric Emergency Procedures, 2nd Edition, C. King and F.M. Henretig, Editors. 2008, Lippincott Williams & Wilkins. p. 483-491.

Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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