IO Access vs central line

[ethilo]

CA-1 here,
I've heard a lot about IO access and how awesome it is. Aside from the primal gut reaction that drilling into someone is barbaric and uncouth, when I see videos of military people doing it on each other for fun it really doesn't actually look that unpleasant of an experience for the patient. After all, the only pain nerves you encounter are on the pinpoint size surface of the periosteum for a microsecond on placing the IO...

My observation is that patients that are undergoing relatively straight-forward procedures but have terrible IV access end up getting central lines for difficult IV access, even when the procedure is not expected to need volume resuscitation.

Why don't we do more IO access instead of going for the CVC in these situations? Is it a stigma thing or is there a medical reason why it would be contraindicated if all you needed it for was induction and occasional pressor bumps intra op? Are there any people out there that go for IO access in the setting of difficult IV access outside of a code scenario?

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[deleted547339]

I use them in the ED frequently.

 

[ethilo]

any complaints, issues, or limitations? pushback or discomfort from ancillary staff?

 

[WholeLottaGame7]

I haven't placed many personally, but all the ones that come in from EMS are either A) infiltrated or B) about to infiltrate. They're good for short-term access but they're not super reliable. Plus, they are often in compartments that can hold a lot of fluid (lower leg, upper arm, etc), so it's hard to tell if you're in the right place until late in the game. I've put a solid 10-20ml/kg into the leg of a kid in the PICU before noticing the leg discrepancy.

 

[fakin' the funk]

My observation is that patients that are undergoing relatively straight-forward procedures but have terrible IV access end up getting central lines for difficult IV access, even when the procedure is not expected to need volume resuscitation.

What's wrong with a central line? Most of the "stigma" of those come from the true risk of placement by newbs (carotid puncture, pneumo, both lower in the era of ultrasound) or risks of long-term use (CLABSI) that have no bearing on the short term?

My personal preference would be to do an ultrasound guided peripheral IV somewhere, anywhere, and then either use that or upgrade once the patient's asleep. Failing that, central line is totally reasonable.

Did you do a medicine prelim year?

 

[ethilo]

My thought is it's faster to place an IO than to place a CVC. If you don't need the CVC then it would require less resources and take less OR time to just run a case through an IO

 

[BLADEMDA]

My thought is it's faster to place an IO than to place a CVC. If you don't need the CVC then it would require less resources and take less OR time to just run a case through an IO

IO lines in adults suck big time. They are for emergency access only and once time allows IV access should be established. As for Central line insertion time most experienced Anesthesiologists can place one in about 4 minutes or so in an emergency situation.

 

[BLADEMDA]

 

[BLADEMDA]

 

[michigangirl]

Bottom line with IOs is that you need to have an eye and feel on the site CONSTANTLY due to the risk of displacement. Unfortunately in the OR unless it's a humeral IO and you have access to head/upper body or you have someone sitting under the drapes it's just not possible. I have only used IOs in an arrest or peri-arrest situation. IOs are SPECTACULAR for emergencies and work just as well as CVCs/IVs but, and it's a big BUT, pushing large volumes of fluid or a pressor through an IO that has been displaced can be catastrophic (ie compartment syndrome, etc.)-- so it's a great short term solution but by no means something to be used in the OR just because getting a central line takes a bit longer.

 

[deleted547339]

I haven't placed many personally, but all the ones that come in from EMS are either A) infiltrated or B) about to infiltrate. They're good for short-term access but they're not super reliable. Plus, they are often in compartments that can hold a lot of fluid (lower leg, upper arm, etc), so it's hard to tell if you're in the right place until late in the game. I've put a solid 10-20ml/kg into the leg of a kid in the PICU before noticing the leg discrepancy.

The same can be said for most PIVs placed by EMS.

 

[link2swim06]

IOs are awesome in the right situation. Especially if you use the ez-io gun (it takes 5-10 seconds?). They are central access technically and can be used as such.

They aren't very good through for large volume blood transfusions...your flow rate will be slowed down.

 

[link2swim06]

CA-1 here,
I've heard a lot about IO access and how awesome it is. Aside from the primal gut reaction that drilling into someone is barbaric and uncouth, when I see videos of military people doing it on each other for fun it really doesn't actually look that unpleasant of an experience for the patient. After all, the only pain nerves you encounter are on the pinpoint size surface of the periosteum for a microsecond on placing the IO...

My observation is that patients that are undergoing relatively straight-forward procedures but have terrible IV access end up getting central lines for difficult IV access, even when the procedure is not expected to need volume resuscitation.

Why don't we do more IO access instead of going for the CVC in these situations? Is it a stigma thing or is there a medical reason why it would be contraindicated if all you needed it for was induction and occasional pressor bumps intra op? Are there any people out there that go for IO access in the setting of difficult IV access outside of a code scenario?

Only thing to note. It ain't the drilling it's the infusion that hurts. Seriously though, if you plan to use an IO on an awake person you better flush with 2% lidocaine BEFORE INFUSING otherwise they are going to be in a world of pain from the fluids rushing into their bone.

 

[Hoya11]

I haven't placed many personally, but all the ones that come in from EMS are either A) infiltrated or B) about to infiltrate. They're good for short-term access but they're not super reliable. Plus, they are often in compartments that can hold a lot of fluid (lower leg, upper arm, etc), so it's hard to tell if you're in the right place until late in the game. I've put a solid 10-20ml/kg into the leg of a kid in the PICU before noticing the leg discrepancy.

^^^ This times a million.

They hurt more.
You cant run anything through them fast.
You cant draw off them.
And most of all they are UNRELIABLE. This issue is close to my heart because I had a similar situation with a dead kid and a leg full of meds only revealed after "dressing for io line" comes down. ANd also in an adult code that was early on that progressed to asystole and death right in front of my eyes despite several rounds of meds, i couldnt believe the guy wasnt bouncing back, and while I cant prove it, I still think it was the damn IO line

 

[btbam]

Would never place an IO for an elective procedure, only codes. Also, infusing through them hurts like a mutha. Any awake pt is gonna be really unhappy with you for that..

 

[Random Anesthesiologist]

My thought is it's faster to place an IO than to place a CVC. If you don't need the CVC then it would require less resources and take less OR time to just run a case through an IO

I have placed more than one femoral line during a code in the time it took medicine residents to locate and assemble the IO apparatus.

They are great in emergency situations where central line placement might be difficult (e.g. Obese, pregnant, renal pts) but central lines can be faster otherwise. And, drilling into bones does hurt.

 

[caligas]

Placing PIVs under ultrasound is all the rage where I work, obviously helpful at times but I always wonder if they are riskier in terms of infiltration.

 

[nimbus]

Placing PIVs under ultrasound is all the rage where I work, obviously helpful at times but I always wonder if they are riskier in terms of infiltration.

I think they are less risky than many blind IVs because you can confirm how much of the catheter as well as the tip is intraluminal.

 

[DocFocker]

Would never place an IO for an elective procedure, only codes. Also, infusing through them hurts like a mutha. Any awake pt is gonna be really unhappy with you for that..

The data disagrees with you. There have been a few studies showing pain scores on placement similar to that of a peripheral IV. The pain with infusion can be mitigated with slow push and lidocaine. I think it has a place outside of emergency resuscitation scenarios.

For instance I was in the ICU the other day and my patient had lost all but one IV for peripheral access. Nurses couldn't find a vein for blood draws and we needed frequent Na checks. I placed an a line for blood draws! My co-anesthesia resident blew the EJ. I looked with the US and only had one AC (couldn't use it for planned PICC placement). There was nothing else but a saphenous and I didn't want to access it. Looked at the RIJ and it was trash. I was the overnight resident and could place lines unsupervised if I wanted. I didn't in this situation. We were running 2% NS for hyponatremia and I was down to 1 PIV. If it blew I was screwed. I would have loved to place an IO in this instance. Surgery scheduled for subdural drainage the next day. They could have used it for 24 hours to get through surgery or could have placed a CL in the OR with trendelenburg and supervision!

 

[nimbus]

The data disagrees with you. There have been a few studies showing pain scores on placement similar to that of a peripheral IV. The pain with infusion can be mitigated with slow push and lidocaine. I think it has a place outside of emergency resuscitation scenarios.

For instance I was in the ICU the other day and my patient had lost all but one IV for peripheral access. Nurses couldn't find a vein for blood draws and we needed frequent Na checks. I placed an a line for blood draws! My co-anesthesia resident blew the EJ. I looked with the US and only had one AC (couldn't use it for planned PICC placement). There was nothing else but a saphenous and I didn't want to access it. Looked at the RIJ and it was trash. I was the overnight resident and could place lines unsupervised if I wanted. I didn't in this situation. We were running 2% NS for hyponatremia and I was down to 1 PIV. If it blew I was screwed. I would have loved to place an IO in this instance. Surgery scheduled for subdural drainage the next day. They could have used it for 24 hours to get through surgery or could have placed a CL in the OR with trendelenburg and supervision!

If you are not comfortable with central lines, that is when you call your attending in. Seriously. That would be optimal care.

 

[pgg]

There was nothing else but a saphenous and I didn't want to access it.

Why not?

 

[Docuronium]

I have placed more than one femoral line during a code in the time it took medicine residents to locate and assemble the IO apparatus.

They are great in emergency situations where central line placement might be difficult (e.g. Obese, pregnant, renal pts) but central lines can be faster otherwise. And, drilling into bones does hurt.

How about I race you then---just because someone who doesn't know how to use it can't doesn't make it a bad tool.

 

[DocFocker]

If you are not comfortable with central lines, that is when you call your attending in. Seriously. That would be optimal care.

I could limp by with the 1 PIV. If it blew I would have called the attending in. I have done 40+ CL but this one didn't look easy.

 

[DocFocker]

Why not?

The access point looked fairly deep. I can't remember how many CM but I wasn't confident there would be much catheter in the vein. I didn't want it to blow and infuse a bunch of 2% into the leg.

 

[WholeLottaGame7]

We were running 2% NS for hyponatremia and I was down to 1 PIV. If it blew I was screwed. Surgery scheduled for subdural drainage the next day.

Combination of all these things = central line. Or if you really don't want to...

The access point looked fairly deep. I can't remember how many CM but I wasn't confident there would be much catheter in the vein. I didn't want it to blow and infuse a bunch of 2% into the leg.

...use one of the long 20g catheters from a brachial a-line kit.

 

[fakin' the funk]

The data disagrees with you. There have been a few studies showing pain scores on placement similar to that of a peripheral IV. The pain with infusion can be mitigated with slow push and lidocaine. I think it has a place outside of emergency resuscitation scenarios.

For instance I was in the ICU the other day and my patient had lost all but one IV for peripheral access. Nurses couldn't find a vein for blood draws and we needed frequent Na checks. I placed an a line for blood draws! My co-anesthesia resident blew the EJ. I looked with the US and only had one AC (couldn't use it for planned PICC placement). There was nothing else but a saphenous and I didn't want to access it. Looked at the RIJ and it was trash. I was the overnight resident and could place lines unsupervised if I wanted. I didn't in this situation. We were running 2% NS for hyponatremia and I was down to 1 PIV. If it blew I was screwed. I would have loved to place an IO in this instance. Surgery scheduled for subdural drainage the next day. They could have used it for 24 hours to get through surgery or could have placed a CL in the OR with trendelenburg and supervision!

So, to summarize:
- a single IV access
- beat up peripheral veins
- ongoing hypertonic therapy
- need for multiple blood draws
- going for surgery tomorrow

And your plan is to cross your fingers? How many indications for a central line does someone need? You know you can lay subdurals flat right?

 

[DocFocker]

So, to summarize:
- a single IV access
- beat up peripheral veins
- ongoing hypertonic therapy
- need for multiple blood draws
- going for surgery tomorrow

And your plan is to cross your fingers? How many indications for a central line does someone need? You know you can lay subdurals flat right?

I did and promptly concluded it was a low yield attempt. Hence me mentioning the ability for trendelendburg in the OR increasing the chance for success in my original post.

 

[deleted162650]

Looked at the RIJ and it was trash.

You know there's other sites for a CVL than the RIJ right??

 

[DocFocker]

You know there's other sites for a CVL than the RIJ right??

NO! enlighten me.

 

[pgg]

Hence me mentioning the ability for trendelendburg in the OR increasing the chance for success in my original post.

I'm sure you know this, but the reason for Trendelenburg isn't to make placing a line technically easier (it does help of course), it's to reduce the risk of a venous air embolism when you've got a needle in the vein open to the air.

 

[Random Anesthesiologist]

How about I race you then---just because someone who doesn't know how to use it can't doesn't make it a bad tool.

I'm not saying it's a bad tool. But I think we can both agree a tool is as good as it's user, and no good when not used properly. In some cases, my example being one, Cvl access is better. Not everyone practices in smooth structured environments. I've also placed plenty of IO access.

 

[vector2]

I could limp by with the 1 PIV. If it blew I would have called the attending in. I have done 40+ CL but this one didn't look easy.

This is bad critical care, and just more fodder for our CCRN "colleagues" to fuel their equality delusions with. Granted, only >2% is an absolute indication for infusion through a CVL, but if this was my family member I'd make damn sure anything which could cause significant phlebitis or other infiltration problems was going in centrally. Critical care (just like anesthesia) isn't about limping by- you should be thinking about risk management and heading off potential future problems (e.g. pt is hyponatremic with a subdural...what if he becomes severely altered at 3am, the IV is blown, and you need to quickly push induction drugs to secure the airway? what if he seizes? what if the bleed starts rapidly expanding?)

You've done 40 lines...were all of these ultrasound R IJ? What about a L IJ, subclav, or femoral for this patient? Take a look at blade's first video- it demonstrates placement of a PIV in the basilic vein. Even the worst vasculopaths who are lacking good A/C's will usually have a robust basilic, cephalic, or deep brachial (caution with these since they're usually in close proximity to the artery).

 

[michigangirl]

Yep, this thread is getting silly. There are many many ICU patients all over the place, kids and adults, who meet the exact same criteria you have stated, DocFocker. 1 PIV that is in danger of going kapoot, challenging access with complex medical needs, sick but not acutely decompensating-- but you just get it done. Put in a central line with whatever means/supervision is needed, or find a vein to put an additional PIV in using ultrasound/modern-day technology. Unless they are acutely going downhill, an IO is not the answer. There are just better options. It's an easy algorithm-- worried your patient might code acutely? Put an IO in. Have time? Do a little planning and put in a CVL or dependable IV.

 

[vector2]

I knew my hubris would come back to bite me. 5'2, 280lb lady in the OR today for open distal pancreatectomy and splenectomy. She is on coumadin for PE but has been bridged with lovenox including a dose this morning. Also on steroids for some rheum thing. She's got one 22g in her elbow that the RN placed. Staff stands there while I put in tube and then promptly leaves. I survey and she's got some potentially suitable veins where the chunk doesn't look too thick. Proud CA-3 that I am, I proceed to blow 4 IVs in a row on insertion. The next 3 (!!!) I manage to get into a vein but each of them blows when I initially flush them. It's been literally 20 minutes since the tube went in but it feels like a goddamned eon. Luckily, surgeon isn't in the room and is in no rush. However, I am sweating profusely at this point. Even the circulator in training for whom I had to spell cefepime three times is staring at me. Both the arm board sheets are covered in blood cause the pt's stupid lovenox is causing her to saturate my failure gauze like there's no tomorrow. I get the U/S and look at each of her upper arms. Not only are her supposedly bigger upper arm veins barely suitable for a 20g, but they're also covered by at least 6cm of blubber. I call staff with tail between my legs so he can watch me place TLC.

 

[ZzzPlz]

I knew my hubris would come back to bite me. 5'2, 280lb lady in the OR today for open distal pancreatectomy and splenectomy. She is on coumadin for PE but has been bridged with lovenox including a dose this morning. Also on steroids for some rheum thing. She's got one 22g in her elbow that the RN placed. Staff stands there while I put in tube and then promptly leaves. I survey and she's got some potentially suitable veins where the chunk doesn't look too thick. Proud CA-3 that I am, I proceed to blow 4 IVs in a row on insertion. The next 3 (!!!) I manage to get into a vein but each of them blows when I initially flush them. It's been literally 20 minutes since the tube went in but it feels like a goddamned eon. Luckily, surgeon isn't in the room and is in no rush. However, I am sweating profusely at this point. Even the circulator in training for whom I had to spell cefepime three times is staring at me. Both the arm board sheets are covered in blood cause the pt's stupid lovenox is causing her to saturate my failure gauze like there's no tomorrow. I get the U/S and look at each of her upper arms. Not only are her supposedly bigger upper arm veins barely suitable for a 20g, but they're also covered by at least 6cm of blubber. I call staff with tail between my legs so he can watch me place TLC.

That staff should have their tail between their legs for leaving so soon. I'd have just put a central line in to start on such a man-bear-pig of a patient. Absolutely indicated.

 

[vector2]

That staff should have their tail between their legs for leaving so soon. I'd have just put a central line in to start on such a man-bear-pig of a patient. Absolutely indicated.

I wouldn't say absolutely indicated. Elective distal pancs/splens aren't really heavy bleeders and this lady didn't have any acute cardiopulmonary issues, so there wasn't really a good indication for central line or CVP monitoring. Me personally, I'd much rather wake up with a couple PIVs and some extra bruises on my arms rather than a five inch, 3 pronged piece of plastic sticking out of my neck and taped to my earlobe. That being said, having someone in the room who can put an end to the madness and tell you to move on when you're floundering is sometimes invaluable.

 

[nimbus]

I wouldn't say absolutely indicated. Elective distal pancs/splens aren't really heavy bleeders and this lady didn't have any acute cardiopulmonary issues, so there wasn't really a good indication for central line or CVP monitoring. Me personally, I'd much rather wake up with a couple PIVs and some extra bruises on my arms rather than a five inch, 3 pronged piece of plastic sticking out of my neck and taped to my earlobe. That being said, having someone in the room who can put an end to the madness and tell you to move on when you're floundering is sometimes invaluable.

The indication is decent IV access without flogging the patient. I'll take the cvl any day.

 

[WholeLottaGame7]

I wouldn't say absolutely indicated. Elective distal pancs/splens aren't really heavy bleeders and this lady didn't have any acute cardiopulmonary issues, so there wasn't really a good indication for central line or CVP monitoring. Me personally, I'd much rather wake up with a couple PIVs and some extra bruises on my arms rather than a five inch, 3 pronged piece of plastic sticking out of my neck and taped to my earlobe. That being said, having someone in the room who can put an end to the madness and tell you to move on when you're floundering is sometimes invaluable.

It's hard, because you get sucked down the rabbit hole and next thing you know it's 30-45 min later and you've made zero progress. I've started just picking an arbitrary time to move on/change something when it comes to lines. No PIV by 3 o'clock? Central line. No radial art line by 1030? DP. Etc etc.

 

[DocFocker]

Yep, this thread is getting silly. There are many many ICU patients all over the place, kids and adults, who meet the exact same criteria you have stated, DocFocker. 1 PIV that is in danger of going kapoot, challenging access with complex medical needs, sick but not acutely decompensating-- but you just get it done. Put in a central line with whatever means/supervision is needed, or find a vein to put an additional PIV in using ultrasound/modern-day technology. Unless they are acutely going downhill, an IO is not the answer. There are just better options. It's an easy algorithm-- worried your patient might code acutely? Put an IO in. Have time? Do a little planning and put in a CVL or dependable IV.

I only brought this patient up because I think that the indications for IO access are expanding outside the realm of code medicine and wanted to generate some discussion. Would I have seriously considered putting in an IO in this patient? No not unless they were coding. Once I am past my comfort zone it's time to call in the attending. Having backup is the benefit of being a resident and learning in a busy ICU. This patient was stable and had access already although crappy as it was. Longer term access could wait a few hours.

 

[teeva]

With time you'll recognize that sometimes straight to GA is easier, or straight to central line is easier. Especially in cases where it's not just a simple lap chole. And also to set limits, like 3 attempts at IV then give up, or 10 mins for spinal then give up. In training everyone likes to point and blame and talk **** about each other, but in the real world you look competent if you're successful on the first attempt of whatever it may be, especially because they don't know your thought process.