Intraosseous Catheter

IO Catheter Placement Video

Introduction

Indications
1. Inability to gain intravenous access in emergency setting
  - 2005 American Heart Assoc resuscitation guidelines: IO is first alternative if IV access is difficult or delayed [1]
  - 2010 ACLS guidelines [2]
2. Central access needed in life-threatening situation, within short period of time (within 2 minutes)
  - Average prehospital time for successful IV placement: 4.4 +/- 2.8 minutes [3]
  - Average time for successful IO insertion: 10 seconds [4]
3. Emergency, trauma, prehospital, military settings[5]
4. Delivery of fluids, drugs needed emergently, with no or difficult venous access
5. Emergent blood sampling
6. Stabilization needed before more stable venous access can be obtained
Absolute Contraindications
1. Definite or possible fracture of ipsilateral limb
  - Can lead to fluid extravasation and compartment syndrome at fracture site
2. Previous attempts at IO placement on ipsilateral limb
  1. Risk of fluid/ vasoconstrictor extravasation
3. Local or proximal vascular injuries
4. Overlying cellulitis or burn injury
5. Patients with high risk of fracture
  - Osteogenesis imperfecta
  - Severe/ advanced osteoporosis
  - Coagulopathies
6. Prior significant orthopedic surgery to considered limb/ joint (eg prosthetic joint or limb)
Potential complications
1. Osteomyelitis
2. Fracture
3. Necrosis of epiphyseal plate
4. Extravasation of fluids or medications
5. Compartment syndrome if administered fluids/ meds extravasate to large degree
6. Failure
7. Injury to others

Anatomic Considerations

Anatomy
- Needle placed into medullary cavity: “highly vascular structure that functions as a non-collapsible vein capable of accepting a large volume of fluid and medications and rapidly delivering them to the central circulation”[5]
- Rate of infusion dictated by:
  1. Size of medullary cavity
  2. Diameter of IO needle
Site selection
1. Many sites possible, various considerations
2. Proximal tibia
  - Preferred for mechanical insertion (EZ IO): easy to locate, flat/ wide surface, minimal overlying tissue [4]
  - Far away from chest, therefore less likely to be dislodged during CPR [5]
3. Proximal humerus
  - Faster delivery of fluids/ medications to circulation
  - Reaches circulation via SVC, bypasses lower body vasculature (important consideration if lower body trauma; risk of extravasation if vasculature compromised)
  - Higher risk of dislodgement if patient receiving chest compressions [6]
4. Sternum
  - Different kit needed (not EZ IO)
  - Possible damage to thoracic organs if done incorrectly, should not be done unless specifically trained or with appropriate supervision
  - Not ideal location if patient might require CPR (risk of dislodgement)

Supplies needed

EZ-IO^® Power Driver
EZ-IO^® Needle Set and EZ-Connect^® Extension Set
EZ-Stabilizer^® Dressing
Non-sterile gloves
Cleansing agent of choice (chlorhexidine or betadine swab)
Luer lock syringe with sterile normal saline flush (5-10 mL for adults)
Sharps container
Additional Equipment/Supplies if Indicated/Ordered:
2% preservative & epinephrine-free lidocaine (intravenous lidocaine)—if patient is conscious
Intravenous fluid
Infusion pressure pump or pressure bag, tubing, 3-way stop cock
Supplies for lab samples

Preparation

Explain procedure to patient, obtain consent (when appropriate)
Clean hands
Identify insertion site
Choose appropriate sized needle
Draw up 10ml sterile saline in syringe and prime the EZ Connect IV tubing
Confirm insertion site
Clean site with chlorhexidine or betadine wash, allow to dry
Connect needle set to driver
Stabilize site and remove needle cap

Insertion

Insert EZ IO needle into selected site: press needle perpendicular to the bone surface until needle tip touches bone
Confirm that at least one black line is visible, otherwise the needle is too short and larger size should be used
Penetrate the bone cortex by squeezing the driver’s trigger and applying gentle, consistent, downward pressure
Release trigger when a sudden “give or pop” is felt upon entry into the medullary space and the desired depth is obtained (a second “pop” suggests penetration of the posterior bone cortex, which can result in extravasation if catheter is used)
Stabilize the catheter hub and remove the driver from the needle
Remove stylet by turning anti-clockwise
Dispose of stylet in a sharps container

Stabilize, confirm location, use

Secure the site with specialized IO dressing (included in kit)
Obtain aspirate for blood sample analysis if required (before connecting primed tubing)
Connect primed EZ Connect tubing to exposed Luer-lock hub, and flush with 10ml of normal saline.
- In a conscious patient, 40mg of 2% lidocaine (maximum 3mg/kg) can be infused slowly prior to flushing to alleviate pain from infusion (infusion is typically more painful than insertion of the IO needle)
Connect the EZ Connect extension set to primed IV tubing
Start infusion using a pressure delivery system
Monitor for complications
Document time and date of placement

Tips

Once IO catheter is inserted, aspirate bone marrow to ensure you’re in correct space (should draw back bloody fluid). If you are unable to aspirate blood, attempt to flush the catheter with a 10ml saline flush to liquefy the gelatinous bone marrow then reattempt aspiration. If you still cannot aspirate bone marrow, do not infuse medications, and attempt IO on another bone.
Its normal to have mild resistance during flushing and slow infusion rates (depending on the anatomy of the intraosseous space or the catheter patency). If initially slow, repeat 20 ml saline flush and be sure to use a pressure bag or positive pressure pump for infusion.
Insertion and continuous infusion can cause some localized pain for conscious patients; administration of 2% lidocaine can be given to control pain (can repeat lidocaine at regular intervals)

What can I give through an IO?

Any medication/fluid that can be infused through a central line can be infused through the IO route
The IO route and the IV route are equivalent (give same doses, same time to onset)
Flow rates: sternum > proximal humerus (~80mL/min) > tibia (15 mL/min)
1 unit of packed RBCs can be administered via the humeral IO route in about 10 minutes

Removal

Removal should be performed:
- Within 24 hours of insertion
- For any signs of erythema, swelling or evidence of extravasation.
To remove: disconnect infusion, attach 10 ml luer-lock syringe to the catheter hub, rotate the catheter clockwise while pulling straight back. Dispose of catheter in bio-hazard container, apply simple dressing

Works Cited

Wilkins LW&. Part 7.2: Management of Cardiac Arrest. Circulation. 2005 Dec 13;112(24 suppl):IV-58-IV-66.
Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;122(18 Suppl 3):S729-767.
Minville V, Pianezza A, Asehnoune K, Cabardis S, Smail N. Prehospital intravenous line placement assessment in the French emergency system: a prospective study. Eur J Anaesthesiol. 2006 Jul;23(7):594–7.
Fowler R, Gallagher JV, Isaacs SM, Ossman E, Pepe P, Wayne M. The role of intraosseous vascular access in the out-of-hospital environment (resource document to NAEMSP position statement). Prehospital Emerg Care Off J Natl Assoc EMS Physicians Natl Assoc State EMS Dir. 2007 Mar;11(1):63–6.
Dev SP, Stefan RA, Saun T, Lee S. Insertion of an Intraosseous Needle in Adults. N Engl J Med. 2014 Jun 12;370(24):e35.
Nickson C. Intraosseous needle insertion [Internet]. LITFL: Life in the Fast Lane Medical Blog. 2012 [cited 2017 May 5]. Available from: https://lifeinthefastlane.com/ccc/intraosseous-needle-insertion/