Intraosseous infusion in children


  • Any fluid or drug that can be given intravenously can be given via an intraosseous needle
  • If rapid fluid replacement is required infuse under pressure using a 50 ml syringe
  • Dilute strong alkalis and hypertonic solutions
  • After giving drugs IO, flush them through
  • Blood drawn from an intraosseous needle can be used for crossmatching and biochemistry


  • Something to clean the skin
  • Intraosseous needle
  • 20 ml syringe filled with normal saline, with short extension set and 3 way tap


Manual needle

  • Identify the appropriate site
  • Avoid fractured bones, or limbs with proximal fractures
  • If possible avoid areas of burns or of skin infection
    • 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
  • For a non-screw-in needle
    • Insert the needle through the skin, and then with a screwing motion perpendicularly / slightly away from the growth plate into the bone
    • There is a give as the marrow cavity is entered
  • For a screw-in needle the give may be less pronounced



Once needle inserted (manula or ez-io), please:

  • Remove the trocar and confirm position by aspirating bone marrow
  • Marrow cannot always be aspirated but it should flush easily
  • Secure the needle and start the infusion


  • Proximal ipsilateral fracture
  • Ipsilateral vascular injury
  • Osteogenesis imperfecta
  • Osteoporosis


  • Failure to enter the bone marrow, with extravasation or subperiosteal infusion
  • Through and through penetration of the bone
  • Osteomyelitis (rare in short term use )
  • Growth plate injury
  • Local infection, skin necrosis, pain
  • Compartment syndrome, fat and bone microemboli have all been reported but are rare


The artwork is by Caroline Wilkinson, and is published with the permission of the BMJ Publishing Group

IO needle 1
IO needle
IO suggested sites leg
Suggested sites

Content by Dr Ian Higginson 01/09/2003. Reviewed by Dr Íomhar O' Sullivan 31/01/2005, 24/05/2007. Last review Dr ÍOS 17/06/21.