Indications and choice of access site
In modern medical practice, intraosseous administration of various transfusion media is used extremely rarely. The main and determining indication for this method is the absolute impossibility of using any other, more traditional routes of administration. A classic example of such a situation is extensive burns, in which access to peripheral and central veins may be physically blocked or associated with fatal risks.
Depending on the clinical situation and the condition of the patient's skin, surgeons distinguish three main sites for establishing intraosseous access:
- Sternum (manubrium or body).
- Iliac crest.
- Calcaneus.
Technique of sternal puncture
Sternal puncture requires strict adherence to the sequence of actions and the use of special instruments.
- Preparation and anesthesia. The patient is in the supine position. Local infiltration anesthesia is performed in the area of the manubrium or body of the sternum, after which the surgical field is thoroughly treated.
- Instrumentation. A Kassirsky needle is used for the puncture — this is a specialized needle equipped with a convenient handle and a special guard to prevent too deep penetration.
- Puncture procedure. The physician inserts the needle strictly along the midline. The needle sequentially passes through the skin, subcutaneous adipose tissue (SAT), and reaches the anterior cortical plate. A certain physical effort is required to overcome this plate.
- Sign of successful access. At the moment of passing through the dense bone tissue and entering the spongy substance (where the bone marrow is located), the surgeon feels a characteristic "give" or "yielding" sensation.
- Position verification. The stylet is removed from the needle, and then aspiration is performed using a syringe. The appearance of bone marrow in the syringe reliably confirms that the needle is in the correct position.
- Preparation for infusion. Before connecting the transfusion set, 3 to 5 ml of a 1–2% procaine (novocaine) solution is injected through the needle. This provides additional anesthesia of the spongy substance itself.
Iliac crest puncture
The pelvic bone is often used as an alternative to the sternum.
- Localization: The needle is inserted strictly into the middle of the posterior third of the iliac crest.
- Morphological rationale: The choice of this specific anatomical zone is not accidental. The spongy bone in the area of the posterior third of the crest has a distinct loose structure. Due to this porous microstructure, the infusion of transfusion media proceeds easily and without significant tissue resistance.
Briefly: answers to topical questions
Which tissue layers does the needle sequentially pass through during a sternal puncture?
During a sternal puncture, the needle sequentially passes through soft tissues and bone structures down to the bone marrow. The puncture is performed strictly along the midline, with the needle overcoming the following layers:
- Skin — the outer integument.
- Subcutaneous adipose tissue — the layer beneath the skin (SAT).
- Anterior cortical plate — overcome with some effort.
- Spongy bone — entry into the bone marrow is accompanied by a characteristic "give" sensation.
What is the allowable rate of fluid administration via intraosseous access?
During parenteral rehydration, including intraosseous administration, the starting infusion rate is 20–60 ml/kg/h depending on the severity of the condition and is maintained until the patient stabilizes. The intraosseous route is used when venous access is impossible. For amiodarone, the loading dose is administered over 60 minutes, and the maintenance infusion is 5–15 mcg/kg/min.
To remember the layers during a sternal puncture, use the chain: Skin → Fat (SAT) → Bone (anterior plate) → Give/Yield (spongy substance).
Class and exam questions
In what cases is intraosseous transfusion justified?
Only when other routes cannot be used. Most often this occurs with extensive burns affecting venous access zones.
How to know that the Kassirsky needle has reached its target?
The surgeon feels a characteristic "give" sensation after overcoming the resistance of the bone. Then, upon aspiration with a syringe, bone marrow should appear in it.
Why is procaine (novocaine) injected before starting the transfusion?
The introduction of 3–5 ml of a 1–2% procaine solution into the spongy substance is necessary to anesthetize the bone marrow before connecting the infusion set.
Why is the middle of the posterior third of the iliac crest chosen for puncture?
In this zone, the spongy bone has a loose structure, which allows transfusion media to easily enter the systemic circulation.
What else to study on this topic
- Massive hemorrhage as an indication for emergency transfusions
- Access features during sudden clinical death
- Specifics of infusions during thoracic surgery
- Alternative accesses: calcaneal puncture
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Other topics in the section "CHAPTER 6. BLOOD TRANSFUSION"
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