Overview
Definition:
Intraosseous (IO) needle removal is the process of safely extracting an IO needle that has been placed for emergent vascular access
Aftercare involves proper wound management and monitoring to prevent complications.
Epidemiology:
IO access is used in approximately 3-10% of pediatric emergency encounters requiring vascular access, making knowledge of its removal and aftercare crucial for all pediatric residents.
Clinical Significance:
Proper IO needle removal and meticulous aftercare are essential to ensure patient safety, promote healing, and prevent potentially serious complications such as infection, fracture, or persistent pain
This knowledge is vital for successful management of critically ill pediatric patients.
Indications For Removal
Definitive Vascular Access:
Once peripheral or central venous access is successfully established, the IO needle is no longer required.
Resolution Of Emergent Condition:
If the patient stabilizes and no longer requires emergent fluid or medication administration via this route.
Discomfort Or Pain:
If the patient experiences significant pain or discomfort at the IO site that cannot be managed.
Suspected Complication:
If there is suspicion of infection, osteomyelitis, fracture, or extravasation at the insertion site.
Removal Procedure
Preparation:
Gather sterile supplies: sterile gloves, antiseptic solution (e.g., chlorhexidine or povidone-iodine), sterile gauze, sterile dressing, and lidocaine (if indicated for conscious patients).
Analgesia:
For conscious or lightly sedated patients, administer local anesthetic such as lidocaine around the insertion site to minimize pain during removal
This may be given subcutaneously or directly into the periosteum.
Needle Extraction:
Grasp the hub of the IO needle firmly
Twist the needle gently counterclockwise while simultaneously pulling straight outwards
Avoid rocking or excessive force, which could damage the bone or surrounding tissues.
Site Compression:
Immediately after removal, apply firm, direct pressure to the insertion site with sterile gauze for at least 5 minutes to control bleeding and promote hemostasis.
Aftercare And Monitoring
Wound Dressing:
Apply a sterile dressing over the insertion site once bleeding has stopped
A transparent dressing or a sterile gauze pad secured with tape can be used.
Pain Management:
Continue appropriate analgesia as needed, especially for younger children or those who experienced significant pain during removal
Monitor for signs of persistent or worsening pain.
Infection Surveillance:
Instruct parents or guardians to monitor the site for signs of infection, including increasing redness, swelling, warmth, purulent discharge, fever, or foul odor
Advise seeking medical attention if any of these occur.
Activity Restrictions:
Advise limiting strenuous activity or weight-bearing on the affected limb for 24-48 hours, particularly if the IO was placed in the tibia or femur, to prevent re-injury or complications.
Complications And Management
Bleeding:
Persistent or excessive bleeding can occur
Continue direct pressure
If uncontrolled, assess for coagulopathy or consider topical hemostatic agents.
Infection:
Local infection (cellulitis) or more serious osteomyelitis can develop
Prompt diagnosis and appropriate antibiotic therapy are crucial
Surgical debridement may be necessary for osteomyelitis.
Fracture:
While rare, fracture of the long bone can occur during insertion or removal
Radiographs are indicated if a fracture is suspected
Management depends on the type and severity of the fracture.
Tissue Damage:
Extravasation of fluids or medications into surrounding soft tissues or subperiosteal space can occur, leading to compartment syndrome or tissue necrosis
Assess for swelling, pain, and signs of compromised circulation
Prompt surgical decompression may be required.
Key Points
Exam Focus:
Understand the indications for removal, the steps of aseptic technique, appropriate analgesia, and crucial aftercare measures to prevent common complications.
Clinical Pearls:
Always ensure definitive venous access is established before removing the IO
Gentle, steady traction with counterclockwise rotation is key
Prolonged, firm pressure is vital for hemostasis.
Common Mistakes:
Inadequate pressure application leading to prolonged bleeding
Failure to assess for definitive venous access
Overlooking signs of infection or fracture
Insufficient pain management post-removal.