Local Anesthesia for Tibial Intraosseous Access

Key Clinical Context

The Association of Anaesthetists guidelines note that aspiration of bone marrow during I/O access is painful in awake patients, establishing the critical need for local anesthesia in conscious individuals 1, 2, 3

Inject 40 mg (2 mL) of 2% lidocaine with epinephrine directly through the I/O needle into the marrow space after confirming proper placement 4, 5
The addition of epinephrine to lidocaine is safe and recommended, as it provides vasoconstriction that slows systemic absorption and prolongs the anesthetic effect 6, 4
Follow the lidocaine injection with a slow saline flush (5-10 mL over 30-60 seconds) to distribute the anesthetic throughout the marrow space and reduce infusion pain 1, 2

The maximum safe dose of lidocaine with epinephrine is 7.0 mg/kg in adults 4, 5
For children, the maximum dose is 3.0-4.5 mg/kg 4
A 40 mg dose (2 mL of 2% lidocaine) is well below toxic thresholds for most patients and provides adequate intraosseous anesthesia 4, 5

Consider infiltrating 1-2 mL of buffered 1% lidocaine with epinephrine at the skin insertion site before I/O needle placement 1, 2, 3
Buffering lidocaine with sodium bicarbonate significantly reduces injection pain and is strongly recommended for subcutaneous infiltration 6, 7
Use a slow infiltration rate to minimize discomfort during administration 7, 4
Warming the lidocaine solution to body temperature (37-40°C) reduces infiltration pain based on high-quality evidence 7, 4, 5

The tibial insertion site is 2 cm distal to the tibial tuberosity and 1 cm medial to the tibial plateau 1, 2, 3
In children, avoid the epiphyseal growth plate to prevent growth disturbances 1, 2, 3

Remove I/O devices as soon as suitable IV access is achieved, ideally within 24 hours of placement 1, 2, 3
Complications include fracture, extravasation, osteomyelitis, infection, compartment syndrome, and pressure necrosis 1, 2, 3