即使是一个经验丰富的麻醉医生，在婴儿快速建立静脉通道时也会遇到各种各样的困难。术中患儿变化莫测，你在术前准备不充分怎么办，术中紧急情况下发现费劲建立的静脉通路不畅，你又该如何？
有人可能嗤之以鼻，说可以进行中心静脉穿刺呀。也可能你百发百中，但是，万发能万中么？如果是一个婴儿，你是不是底气还这么足呢？等我介绍完骨髓内输液，你再评论如何？
骨髓腔由于被骨性结构所支持，不像血管腔那样会因为血容量不足而塌陷。骨髓丰富血窦中的静脉血通过髓静脉系统、营养静脉与穿支静脉而进入全身循环。因此液体活药物注射入骨髓腔后会很迅速吸收入体循环，骨髓内输液利用这一途径达到输液目的。由于随年龄增长小儿长骨中红骨髓逐渐被血管少的黄骨髓代替，所以骨髓内输液仅可能适合于仍有红骨髓的小儿（小于6岁）。
指征：骨髓内输液用于患儿紧急用药，又缺乏静脉通道时。常用于心跳骤停、严重烧伤、休克、危及生命的癫痫状态。
禁忌：较少，骨折或骨髓穿刺失败后再穿刺可能会造成液体渗漏，必须选取健侧穿刺。骨质疏松或骨发育不良禁忌。穿刺部位有蜂窝组织炎、皮肤感染者禁忌。因为可能存在脂肪栓塞风险，右向左分流的小儿应谨慎使用。
并发症：由液体渗漏形成的一些并发症，严重的如筋膜室综合症。
骨髓内输液装置：有正规产品。本文只分析原理。
部位：最常用部位为胫骨近端。
在患儿血流动力学稳定后应尽快建立静脉通道，撤出骨髓内输液。
如有兴趣，请查阅相关内容。如《婴幼儿麻醉学》。
网友[yzhzcl]：
2005年国际心肺复苏指南要求：复苏药物静脉或者骨髓给药。
网友[qjm770628]：
骨髓输液在《婴幼儿麻醉学》上确有详细的讲述，但在实际工作中，又有多少家医院有一整套正规骨髓内输液装置？所以利用手边现有的东西才是比较现实的。我也没做过这种操作，也没机会学习过。但我认为硬膜外穿刺针或许能派上一点用场（管径大，针硬便于穿刺），反正骨髓输液也是权宜之计，待穿刺成功后简单固定下，想办法将液体和急救药物用下去，等外周循环改善后再建立外周静脉通路。
留置针外套管软，进骨髓腔可能难度很大！
十六号针头是个不错的选择，固定和补液都方便，抢救病人方便使用。时间就是生命呀！
网友[ximingchen]：
Intraosseous Infusion
Intraosseous infusion is an alternative technique in providing a rapid and effective route for fluid resuscitation and medication administration for pediatric and adult patients in an emergency situation when intravenous cannulation is unsuccessful or cannot be obtained in a reasonable period of time.
INDICATIONS
Burns (extensive)
Cardiac Arrest
Coma (unconscious/unresponsive)
IV access is unobtainable by other means
Medication administration which cannot be administered by other routes (i.e. IV, ET, IM, SC)
Multi-systems Trauma
Shock and/or severe dehydration
Status Epilepticus
CONTRAINDICATIONS
Injury to Tibia
Recent fracture to tibia
Osteogenesis Imperfecta (congenital disease-fragile bones)
Osteoporosis
Infection of extremity (of the intended puncture site)
Burns of the extremity
EQUIPMENT
INTRAOSSEOUS infusion needle (16, 18 or 20 ga)
5 or 10 cc syringe
Micro set IV tubing and IV solution (NS)
Betadine Swab and tape
POTENTIAL COMPLICATIONS
Delay in transportation
Osteomyelitis, subperiosteal infusion, and infection
Subcutaneous abscess, epiphyseal trauma, fat embolus
Thrombosis
Tibial fracture
Intraosseous Infusion (con't)
ASSESSMENT PRIORITIES (if not already done or in progress)
1. Maintain patent ABCs. Assist ventilations as needed. (Assume spinal injury based upon mechanism of injury)
2. Administer high concentration of oxygen by mask or bag-valve-mask (BVM).
3. Ascertain appropriate history related to the event, past medical history, medications, drug allergies and physician.
PROCEDURE
1. Perform enroute to hospital (if possible)
2. Place the patient in a supine position.
3. Locate an appropriate site for intraosseous infusion.
a. for children the proximal tibia is an appropriate site.
b. When using the anterior medial surface of the proximal tibia, the tibial tuberosity is palpated with the index finger and the medial aspect of the tibia is grasped with the thumb. Half way between these two points or approximately 1-2 cm distally is the optimal point for needle insertion.
c. If the distal tibia is used the optimal location is the medial surface of the tibia proximal to the medial malleolus.
4. Select the appropriate site and prepare the area using an aseptic technique.
5. Place the intraosseous needle, using a twisting (screwing) motion with the needle perpendicular to the bone and the bevel pointing away from the joint's base. A rotary motion is used with a downward pressure until there is a slight decrease in resistance indicating that the cortex of the bone has been punctured. The needle usually does not need to be advanced further. The distance from the skin through the cortex is rarely more than 1 cm in an infant or a child and penetration to this depth is usually adequate. At this point remove the stylette. To confirm the position of the needle in the marrow cavity, a syringe is attached and blood or marrow is aspirated. Once the bone marrow needle is confirmed to be in the marrow, a standard IV tubing can be attached to administer fluids and/or medications.
6. Observe for extravasation of fluids into surrounding soft tissue.
7. The patient should be transported as soon as possible, if not already enroute to the hospital.
http://www.mass.gov/dph/oems/emt/intra_infusion.doc
骨髓输液穿刺器械及示意图
编辑：西门吹血
