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  • Writer's pictureLouie Romanos

Is driver assisted IO insertion more effective than manual IO for pediatric resuscitation?

Updated: Feb 27, 2019

Without question, IO access has revolutionized our approach to fluid resuscitation in infant and pediatric populations.

It provides immediate access to the hemodynamically compromised patient and should be considered when peripheral access is questionable.

There exists some debate with front line health care professionals regarding the exact mechanism for obtaining IO access.

Most major tertiary and community hospitals follow the practice of either manual IO or EZ-IO for establishing access in emergent pediatric situations.

The reason for considering manual IO insertion is related to the composition of pediatric bone.

Specifically, its thinner and more malleable compact layer allow for easier insertion and more tactical feedback when compared to adult bone.

The benchmark for validating one approach over the other needs to consider speed and accuracy.

Accuracy is paramount when considering either option

In a study by Pifko et al.(2017), researchers found a higher first attempt success rate with manual IO placement when comparing pediatric patients less than 8kg. The overall success rate between these two approaches was not statistically different (Pifko et al.(2017).

The later was supported in a study using a simulated infant and child tibia for evaluating the efficacy of manual vs. driver assisted IO insertion (Ohchi, Komasawa, & Minami(2015).

Overall, there seems to be some benefit for using manual IO placement in the smaller population size. This feature could be attributed to the infant bone's smaller surface area for insertion. In addition, the likelihood of not feeling the change in resistance once the intraosseous space is entered is a real possibility since infant long bones have a thinner cortical layer. The inherent power and speed of the EZ-IO system could make locating the medullary space challenging.

The Likelihood of ROSC with improved neurological outcome is greater when CPR is initiated without delay

The importance of achieving quick access for fluid resuscitation is vital for increasing survival. When compared to the EZ-IO system, manual IO access had a faster time to placement in both the less than 8kg and greater than 8kg groups (Pifko et al.(2017). In the simulated bone study by Ohchi, Komasawa, & Minami(2015), the speed to placement for the EZ-IO system was significantly faster than the manual system.

The study by Ohchi, Komasawa, & Minami(2015) has one important limitation when interpreting the findings. Specifically, it was performed on simulated bone which is different from real human bone.

Which is the better option?

The research suggests that success rates between the two options are similar. When considering a smaller patient, manual insertion may be faster and more accurately performed.

Clinician preference, confidence, and experience should dictate which choice is used. The more important point to remember is that hemodynamic access should not be delayed by multiple intravenous attempts. The IO route is a quick and safe option that provides all the benefits of the intravenous route.


1. Pifko, E.L., Price, A., Busch, C., Smith, C., Jiang, Y., Dobson, J., Tuuri, R. Observational review of paediatric intraosseous needle placement in the peaediatric emergency department. Journal of Paediatrics and child health, 54(2018), 546-550.

2. Ohchi, F., Komasawa, N., Mihara, R., Minami, T. Comparison of manual bone marrow puncture needle for intraosseous access; a randomized simulation trial. Springer Plus, 4(2015), 211.

#PALS #PALScertification#PALSprovider#EZ-IOsystem#IOaccess

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