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Board Questions

1. At what point should intraosseus access be removed?

a) 24 hours
b) 48 hours
c) 6 hours
d) There is no limit on the duration of intraosseus access

2. Your patient is in hypovolemic shock and requires aggressive fluid resuscitation. They have the following access points. Which would be best used to push fluid?

a) 4Fr double lumen PICC line in R arm
b) Radial arterial line
c) 22 gauge PIV in left arm
d) 10 Fr R femoral vein dialysis catheter

3. Which is not the preferred approach for the corresponding access? 

a) Right upper extremity basilic or cephalic vein, PICC
b) Junction of middle/distal third of the right clavicle, subclavian venous catheter
c) Humeral head, intraosseus
d) R central/medial approach, Internal Jugular venous catheter



ANSWERS & EXPLANATIONS

1. A. IO access should be removed by 24 hours at the latest. Ideally, once venous access is obtained the IO line can be removed to reduce the risk of complications such as osteomyelitis.

2. C. Flow through a tube is governed by Poiseuille's law, which states that the resistance through a tube is proportional to the length and inversely proportional to the radius to the 4th power. Hence, a small long tube like a PICC line would have a lot of resistance and be difficult to push volume through. The arterial line should be used for monitoring but not fluid resuscitation. The hemodialysis catheter is generally locked with high concentration heparin and thus, while it could be used in an emergency, is generally not used for infusions given the risk of inadvertent systemic heparinization.

3. C While the humeral head is approved in adults, it is not the standard approach for pediatric intraosseus access (proximal tibia, distal femur, distal tibia). The subclavian should be approached from the junction of the middle/distal third of the R clavicle, the IJ is generally approached via the medial/central method using the apex of the triangle formed by the clavicle and the sternal and clavicular heads of the sternocleidomastoid muscle, with the R side approached. PICC lines generally are inserted into the basilic or cephalic veins, with the R side preferred.

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