Intraosseous access: Difference between revisions

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===Indications===
==Indications==
*immediate access required for administration of drugs/fluids
[[File:ez-IO.jpg|thumbnail|3 EZ-IO sizes]]
*cardiac arrest, resuscitaion when no other IV in place
*Do not use IO for more than 24 h (ideally place the IO for immediate resus needs, then establish peripheral or central lines as needed)


===Contraindications===
*Immediate vascular access required for administration of drugs/fluids
*osteoporosis
*Cardiac arrest, resuscitation when no other IV in place
*osteogenesis imperfecta
*fractured bone
*recent IO infusion in same bone
*insertion at site of cellulitis, infection, or burn


===Equipment===
[[File:IO sizes.JPG|thumbnail|15 Gauge IO sizes]]
*multiple different types of IO needles and products available
*EZ-IO device used at HUCLA (equipment stored in green box in medicine room in adult ED, or in cabinets of room 4 in peds ED)


#EZ-IO drill
==Contraindications==
#Appropriate IO needle with extension set
*Osteoporosis
#chloraprep
*[[Osteomyelitis]]
#NS flush
*Osteogenesis imperfecta
#Lidocaine (2% lidocaine without epi - cardiac lidocaine)
*[[Fractures_(Main)|Fractured bone]]
*Recent IO infusion in same bone
*[[Cellulitis]], Infection, or Burn, at insertion site


===Site Selection (for EZ-IO system)===
==Equipment==
#Proximal Tibia- 2 finger breadths below tibial tuberosity (1-3 cm) on medial, flat aspect of tibia
*EZ-IO drill (other products/brands available)
#Distal Tibia- medial surface at junction of medial malleolus and shaft of tibia, posterior to to greater saphenous vein
*Appropriate IO needle with extension set
#Proximal humerus (adults only, use yellow needle)
*Chloraprep or alcohol swabs
*Saline Flush
*[[Lidocaine]] (2% lidocaine without epi)


===EZ-IO Needle selection (based on weight of patient)===
==Site Selection==
#Pink 15mm (3-39kg)  
*Proximal Tibia- 2 finger breadths below tibial tuberosity (1-3 cm) on medial, flat aspect of tibia
#Blue 25mm (40kg and above)  
*Distal Tibia- medial surface at junction of medial malleolus and shaft of tibia, posterior to to greater saphenous vein
#Yellow 45mm  (excessive tissue)
*Proximal humerus (adults only, use yellow needle) <ref> http://www.acep.org/WorkArea/DownloadAsset.aspx?id=48943 </ref>
**keep arm adducted and internally rotated (hand on bellybutton)
**slide fingers up humerus until you feel a notch (surgical neck)
**insert IO 1cm above surgical neck into the greater tubercle
**immobilize arm or IO will displace (no abduction at shoulder)
*Distal Femur (generally only in infants and children)
*Pelvic ASIS


===Procedure===
==EZ-IO Needle selection (based on weight of patient)==
#identify landmarks
*Pink 15mm (3-39kg)  
#prep skin
*Blue 25mm (40kg and above)  
#place appropriate needle on drill and remove safety cap
*Yellow 45mm&nbsp; (excessive tissue)
#ADVANCE needle through skin to bone
#DRILL needle perpendicular into bone at site with gentle, constant pressure
#when needle tip contacts bone there should be 5mm of catheter visible outside of skin&nbsp;(if not you may need a longer needle)  
#continue drilling through bone until "give"&nbsp;or "pop" occurs and needle tip enters medullary space
#remove stylet
#attach the manuacturer's extension set (helpful if this is pre-flushed with saline and/or lidocaine)  
#aspirate blood/marrow to confirm placement
#flush saline through extension set to ensure good flow
#if pt is awake, slowly infuse&nbsp;2% lidocaine (cardiac lidocaine) 2-3mL through&nbsp;the IO&nbsp;line (IO&nbsp;infusion is painful)  
#apply dressing
#'''REMOVAL:'''&nbsp;detach extension tubing. place a 12mL&nbsp;empty syringe on IO&nbsp;luer lock. twist clockwise while gently and slowly applying in-line traction until removed. apply dressing.&nbsp;


===Complications===
==Procedure==
*incomplete penetration of cortex
*Identify landmarks
*penetration of posterior cortex
*Clean skin
*pain
*Place appropriate needle on drill and remove safety cap
*infection
*ADVANCE needle through skin to bone
*compartment syndrome
*5 mm of the catheter (at least one black line) must be visible outside the skin
*growth plate damage
*DRILL needle perpendicular into bone at site with gentle, constant pressure
*fat embolism
*When needle tip contacts bone there should be 5mm of catheter visible outside of skin (if not you may need a longer needle)
*Continue drilling through bone until "give" or "pop" occurs and needle tip enters medullary space
*Remove stylet (''caution: stylet is extremely sharp'' - place in sharps container)
*Attach the manuacturer's extension set (helpful if this is pre-flushed with saline and/or lidocaine)
*Aspirate blood/marrow to confirm placement
*If patient is awake, slowly infuse 2% lidocaine (cardiac lidocaine) 2-3mL through the IO line (IO infusion is painful as the marrow cavity expands)
*Flush saline through extension set to expand marrow cavity (helps ensure adequate flow rates)
*Apply dressing


===Labs?===
===Removal===
*Blood drawn from an IO&nbsp;can be used for type and cross, chemistry, blood gas.  
*Detach extension tubing. Gently and slowly apply in-line traction (i.e. pull straight out - do not rock back and forth). May rotate clockwise while applying in-line traction.
*CANNOT&nbsp;use IO&nbsp;blood for CBC
**Can attach syringe via luer lock to act as handle
*Apply dressing.


===IO&nbsp;Medications===
(IO's should not be left in more than 72-96 h and ideally removed after initial resuscitation once more secured access is achieved<ref>Dev SP, et al. Insertion of an intraosseous needle in adults. N Engl J Med. 2014; 370:e35.</ref>)
 
==Complications==
*Compartment syndrome
*Incomplete penetration of cortex
*Penetration of posterior cortex
*Infection (cellulitis, osteomyelitis)
*Fracture
*Growth plate damage
*Fat embolism
 
==Labs drawn via IO==
*Blood drawn from an IO can be used for type and cross, chemistry, blood gas.
**There is not good correlation with Sodium, Potassium, CO<sub>2</sub>, and calcium levels.<ref name="miller">Miller LJ. et al A new study of intraosseous blood for laboratory analysis.Arch Pathol Lab Med. 2010 Sep;134(9):1253-60.</ref>
**Potassium is often elevated due to hemolysis
*CANNOT use IO blood for CBC
**WBCs are higher and platelet counts are lower<ref name="miller"></ref>
*Only need to discard 2mL of blood prior to sending to lab
 
==IO Medications==
*Any medication that can be given in peripheral IV can be given through IO  
*Any medication that can be given in peripheral IV can be given through IO  
*Same doses as IV&nbsp;meds  
**[[Epinephrine]] infused via the intraosseous humeral site has the identical peak serum concentration as if it were instilled via a subclavian central line<ref>Kramer GC, Hoskins SL, Espana J, et al. Intraosseous drug delivery during cardiopulmonary resuscitation: relative dose delivery via the sternal and tibial routes. Acad Emerg Med 2005;12(5):s67.</ref>
**[[RSI]] medications can be given through IO with the same efficacy<ref>Barnard, et al. Rapid sequence induction of anaesthesia via the intraosseous route: a prospective observational study. Emerg Med J. 2014; Jun 24. pii: emermed-2014-203740. [Epub ahead of print]</ref>
*Same doses as IV meds  
*Follow with flush
*Follow with flush
*Drips or IV fluids should be given with pressure bag or infusion pump
==IO and CT contrast==
*Overall safe and effective
*Case reports with successful venous opacification in a trauma patient <ref> Knuth, et al. Intraosseous Injection of Iodinated Computed Tomography Contrast Agent in an Adult Blunt Trauma Patient. Annals of Emergency Medicine. 2011; 57 (4) 382-386 </ref>
*Successful CTA [[PE]] protocol reported <ref> Ahrens, et al. Successful Computed Tomography Angiogram Through Tibial Intraosseous Access: A Case Report. Journal of Emergency Medicine. 2013; 45 (2): 182-184 </ref>
*Connect power injector straight to IO needle. Do not use IO extension tubing (cannot withstand pressure) <ref> Miller, et al. Utility of an intraosseous vascular system to deliver contrast dye using a power injector for computerized tomography studies. Annals of Emergency Medicine. 2011; 58 (4) 240-241. </ref>
==See Also==
*[[Access options]]
==References==
<references/>


[[Category:Procedures]]
[[Category:Procedures]]
[[Category:Critical Care]]

Revision as of 18:32, 20 August 2017

Indications

3 EZ-IO sizes
  • Immediate vascular access required for administration of drugs/fluids
  • Cardiac arrest, resuscitation when no other IV in place
15 Gauge IO sizes

Contraindications

Equipment

  • EZ-IO drill (other products/brands available)
  • Appropriate IO needle with extension set
  • Chloraprep or alcohol swabs
  • Saline Flush
  • Lidocaine (2% lidocaine without epi)

Site Selection

  • Proximal Tibia- 2 finger breadths below tibial tuberosity (1-3 cm) on medial, flat aspect of tibia
  • Distal Tibia- medial surface at junction of medial malleolus and shaft of tibia, posterior to to greater saphenous vein
  • Proximal humerus (adults only, use yellow needle) [1]
    • keep arm adducted and internally rotated (hand on bellybutton)
    • slide fingers up humerus until you feel a notch (surgical neck)
    • insert IO 1cm above surgical neck into the greater tubercle
    • immobilize arm or IO will displace (no abduction at shoulder)
  • Distal Femur (generally only in infants and children)
  • Pelvic ASIS

EZ-IO Needle selection (based on weight of patient)

  • Pink 15mm (3-39kg)
  • Blue 25mm (40kg and above)
  • Yellow 45mm  (excessive tissue)

Procedure

  • Identify landmarks
  • Clean skin
  • Place appropriate needle on drill and remove safety cap
  • ADVANCE needle through skin to bone
  • 5 mm of the catheter (at least one black line) must be visible outside the skin
  • DRILL needle perpendicular into bone at site with gentle, constant pressure
  • When needle tip contacts bone there should be 5mm of catheter visible outside of skin (if not you may need a longer needle)
  • Continue drilling through bone until "give" or "pop" occurs and needle tip enters medullary space
  • Remove stylet (caution: stylet is extremely sharp - place in sharps container)
  • Attach the manuacturer's extension set (helpful if this is pre-flushed with saline and/or lidocaine)
  • Aspirate blood/marrow to confirm placement
  • If patient is awake, slowly infuse 2% lidocaine (cardiac lidocaine) 2-3mL through the IO line (IO infusion is painful as the marrow cavity expands)
  • Flush saline through extension set to expand marrow cavity (helps ensure adequate flow rates)
  • Apply dressing

Removal

  • Detach extension tubing. Gently and slowly apply in-line traction (i.e. pull straight out - do not rock back and forth). May rotate clockwise while applying in-line traction.
    • Can attach syringe via luer lock to act as handle
  • Apply dressing.

(IO's should not be left in more than 72-96 h and ideally removed after initial resuscitation once more secured access is achieved[2])

Complications

  • Compartment syndrome
  • Incomplete penetration of cortex
  • Penetration of posterior cortex
  • Infection (cellulitis, osteomyelitis)
  • Fracture
  • Growth plate damage
  • Fat embolism

Labs drawn via IO

  • Blood drawn from an IO can be used for type and cross, chemistry, blood gas.
    • There is not good correlation with Sodium, Potassium, CO2, and calcium levels.[3]
    • Potassium is often elevated due to hemolysis
  • CANNOT use IO blood for CBC
    • WBCs are higher and platelet counts are lower[3]
  • Only need to discard 2mL of blood prior to sending to lab

IO Medications

  • Any medication that can be given in peripheral IV can be given through IO
    • Epinephrine infused via the intraosseous humeral site has the identical peak serum concentration as if it were instilled via a subclavian central line[4]
    • RSI medications can be given through IO with the same efficacy[5]
  • Same doses as IV meds
  • Follow with flush
  • Drips or IV fluids should be given with pressure bag or infusion pump

IO and CT contrast

  • Overall safe and effective
  • Case reports with successful venous opacification in a trauma patient [6]
  • Successful CTA PE protocol reported [7]
  • Connect power injector straight to IO needle. Do not use IO extension tubing (cannot withstand pressure) [8]

See Also

References

  1. ↑ http://www.acep.org/WorkArea/DownloadAsset.aspx?id=48943
  2. ↑ Dev SP, et al. Insertion of an intraosseous needle in adults. N Engl J Med. 2014; 370:e35.
  3. ↑ 3.0 3.1 Miller LJ. et al A new study of intraosseous blood for laboratory analysis.Arch Pathol Lab Med. 2010 Sep;134(9):1253-60.
  4. ↑ Kramer GC, Hoskins SL, Espana J, et al. Intraosseous drug delivery during cardiopulmonary resuscitation: relative dose delivery via the sternal and tibial routes. Acad Emerg Med 2005;12(5):s67.
  5. ↑ Barnard, et al. Rapid sequence induction of anaesthesia via the intraosseous route: a prospective observational study. Emerg Med J. 2014; Jun 24. pii: emermed-2014-203740. [Epub ahead of print]
  6. ↑ Knuth, et al. Intraosseous Injection of Iodinated Computed Tomography Contrast Agent in an Adult Blunt Trauma Patient. Annals of Emergency Medicine. 2011; 57 (4) 382-386
  7. ↑ Ahrens, et al. Successful Computed Tomography Angiogram Through Tibial Intraosseous Access: A Case Report. Journal of Emergency Medicine. 2013; 45 (2): 182-184
  8. ↑ Miller, et al. Utility of an intraosseous vascular system to deliver contrast dye using a power injector for computerized tomography studies. Annals of Emergency Medicine. 2011; 58 (4) 240-241.
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