Interosseous central access underutilized?

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Bigeminy

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Hey all,

I'm an intern who started this July and am regularly involved in medical resuscitations and traumas. I've noticed that it can take quite long sometimes to get access, even with our great nurses trying and even with use of the ultrasound for peripheral/central lines. It seems that even with extremely edematous patients using the EZ-IO is trivial. Even I can do it, and you have instant central access.

My question is why isn't this used more? It seems like a great idea when you need immediate access. The ICU team has scoffed at us the two times I have seen it used (what do you mean the patient only has an IO?), but in my humble intern opinion I think it's something we could use more with patients who are difficult sticks.

I believe they are safe to leave in for 24-48 hours, so why isn't this used more? Is there something obvious I'm missing?
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it is scoffed at by ICU, as they love central lines, and some can get them incredibly quick. in a need for access crashing patient IO is an excellent method of access, almost every med you can go through it, and when using humeral(I recommend) delivery to heart is quick enough you can use adenosine, and high volume fluid can be given through it. After you get your resus however would be a good time to get you central line, as they can stay in longer, and the floor wont call and bitch since they dont know how to manage IOs.
 
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I don't think IOs are considered central access.
 
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What meds canNOT be given IO? Calcium Chloride ok??
 
nyr77 said:
it is scoffed at by ICU, as they love central lines, and some can get them incredibly quick. in a need for access crashing patient IO is an excellent method of access, almost every med you can go through it, and when using humeral(I recommend) delivery to heart is quick enough you can use adenosine, and high volume fluid can be given through it. After you get your resus however would be a good time to get you central line, as they can stay in longer, and the floor wont call and bitch since they dont know how to manage IOs.
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Interesting about adenosine. Yeah, I realize the central lines can stay in longer (except femoral lines have the same ~2 day window as an IO, right?). It seems like such a time saver, but maybe that's just because right now getting everything together for a central line and getting it done takes me a half hour.

Also, your user name -- rangers fan?
 
Boatswain2PA said:
What meds canNOT be given IO? Calcium Chloride ok??
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Anything you can you can put through a central line you can put through an IO. You can even run contrast dye through it if needed. I think there was one animal study where they found some local inflammation issues after running hypertonic saline for a prolonged period of time.

Also the flow is pretty good in IOs, contrary to popular belief the onset of action and peak drug levels are comparable to an IV.

Bigeminy said:
Interesting about adenosine. Yeah, I realize the central lines can stay in longer (except femoral lines have the same ~2 day window as an IO, right?). It seems like such a time saver, but maybe that's just because right now getting everything together for a central line and getting it done takes me a half hour.
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Even though the data says 2 days you have to watch out for your hospital's policies. Mine doesn't let them stay in for more than 24 hours even though the evidence says otherwise.
 
Love IOs.

Unfortunately I've had the same experience as you OP.

I think part of it is just that most physicians have little to no experience with IOs unless they have an EMS background and many others seem to be misinformed about what meds can go though them. As a result, they're more comfortable sticking w/ venous access only.
 
I've been told you can give everything except blood products.
 
bougiecric said:
Everything, including blood products, can be given.
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Everything except chemo... but mostly because chemo isn't emergent and the IO was only approved for emergent access situations.

Also, I'm unaware of any data on Intralipid via the osseous route... can make the argument either way for pro (central access) and con (relative viscosity).

Otherwise, drill baby drill!

-d
 
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They're great as emergency, quick access. In the right patient (ideally unconscious), I allow two attempts at PIV, and then do an IO. I've had them fail or malfunction enough to lose some enthusiasm for them, but they're still my go-to when a PIV isn't obtained quickly. I don't think of it as a central line. I wouldn't give CaCl through it, but I would try a vasopressor as a temporary measure. When things settle out, I'd put in a central line and leave the IO. It can be removed later.

I listen to consultant and specialists' opinions and then decide for myself what seems right for me. There are many ways to skin a cat.
 
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I haven't seen adenosine work through an IO yet but that may be because its very rare that I do see that attempted.

Very interesting about the contrast dye. I hadn't considered that. There are multiple situations I've seen no peripherals possible even under ultrasound and the decision comes down to doing a central line or doing the CT wo/contrast. If the patient does not need meds/fluids would anyone consider placing an IO for purpose of obtaining a contrast study?
 
joeDO2 said:
I haven't seen adenosine work through an IO yet but that may be because its very rare that I do see that attempted.

Very interesting about the contrast dye. I hadn't considered that. There are multiple situations I've seen no peripherals possible even under ultrasound and the decision comes down to doing a central line or doing the CT wo/contrast. If the patient does not need meds/fluids would anyone consider placing an IO for purpose of obtaining a contrast study?
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In that case I'd opt for a central line. The IO isn't exactly going to be 'pain-free.' I have only seen IOs being used in emergent/urgent scenarios (the unstable trauma pt, coding or near coding pt, etc..).
 
IO's are great, but they are not a replacement for a central line. This may be what your ICU colleagues are giving you grief about. I place the IO get things started and place a resus line like a subclavian cordis immediately. If you need the ports, place a double lumen infusing catheter through the cordis (BiCVP, SLIC whatever you wanna call it at your shop).

So quick IO (or multiple IOs, probably humeral >> tibial with pressure bag) to get the BP up get the patient tubed etc..but don't forget a subclavian can be placed rapidly in obese, hypotensive patients by skilled providers. If you have time use US.
 
The ED I work at almost never does IOs. I've only seen them done on patients actively coding. Ultrasound guided IVs and EJs seem to be much more popular, even though IOs are much quicker and easier IMO. On the other hand though, I've never come across a patient who I couldn't get an IV in. They call me the IV Guru ;)
 
NotAnOperator said:
The ED I work at almost never does IOs. I've only seen them done on patients actively coding. Ultrasound guided IVs and EJs seem to be much more popular, even though IOs are much quicker and easier IMO. On the other hand though, I've never come across a patient who I couldn't get an IV in. They call me the IV Guru ;)
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You'll come across one soon enough.

IOs should be the default emergent access line. They are faster than CVLs and IV's and when you need emergent access there is no reason not to do it.

Patients in this situation who are then going to the ICU need longer term access, however. Once the code is resolved or what have you, a CVL should be placed if you do not have adequate peripheral IV access. These patients should not be admitted to the ICU with only an IO. To the OP, that is what the ICU is giving you grief about. They cannot obtain certain labs such as a CBC from that IO and as a general rule these patients need multiple lines/ports for multiple medications to be running simultaneously (sedatives, Abx, fluids, pressors, etc.).
 
EvoDevo said:
You would be incorrect.
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Not sure how IO is considered central access - you can't draw labs, can't transduce a CVP, etc.
 
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jwk said:
Not sure how IO is considered central access - you can't draw labs, can't transduce a CVP, etc.
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It's meant in the ability to infuse pressors. However, I thought it was only humeral IOs could be used for pressors.
 
I use IO's quite a bit, esp humeral. the last time I did a blind central line was b/c there was no IO in the floor crash cart. otherwise it's quick, effective, and enough to stabilize and out of the ED (our ICU/ccu wants to do their own lines upstairs).
even with sickle cell kids in crisis. they've been stuck 1000 times. why torture the kid any further? I drill them, pain control/fluid them up, get a IV line later
pain? only on the initial push. I load the saline lock with preserve free lido (or cardiac lido) only. no saline. very, very slowly push. it seems like it takes forever but it's really only a few min. if there's still pain with saline push, then repeat.

I taught ultrasound at a comm ER in AL where they use IO just to send a pt for hip surgery. it's a standing order for the RN! like everything in medicine, it'll take time to catch on or fizzle out to the newest gadget
 
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