IO line questions

[LouisianaDoctor]

Hi all,

I'm a FM resident that moonlights regularly in the ER at my hospital. Reasonable volume, and rapidly growing (almost 5k visits last month.) We have fantastic docs but some are old school. About half use US, the others don't.

I've read about IO lines and how superior they are to central lines in terms of success rates, ease, and speed. I've never placed one. I want to make a presentation to convince our ER to get a drill and educate us on them.

Anyway, I have a few questions:

1. How do you remove a IO line, and what care is needed for the IO site afterwards? I mean do you just pull the line, hold pressure, and put gauze and a bandaid?

2. My research says IO lines shouldn't really stay in for more than a day. So I'm looking for a reasonable transition (what line to use after the IO is no longer needed) protocol. It seems reasonable that if an IO line is placed, the patient is clearly going to be admitted, so it would be reasonable to just order a PICC line for the next morning and remove the IO line then, or even if peripheral IV access is obtainable after volume resuscitation then use that instead.

3. Don't laugh: it seems no analgesia is used for placing the line. (I don't mean the lidocaine flush after the men is placed.) If you are placing an IO line because you have a severely volume depleted patient, or a very difficult stick, but the patient isn't obtunded, would you provide any local analgesia first?

4. Any thoughts on the costs of a drill? It seems the drills are around $500 with educational sets around $800. How much are the needles themselves? And what is the cost of a central line kit? (To compare them.)

In my limited ER experience, I've seen extremely capable doctors that I would absolutely trust my life with, and my families life (and I have) fail at placing a central line in a difficult patient, and I know an IO like would have taken one minute to place and not have failed. It just seems like these are such great options.

Thank you for any wisdom you can share. (Please forgive me if my phone has changed line into like and I missed it)

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[MSmentor018]

1. yep but I drilled someone in the ER, I'd leave it in until something else was placed. assuming they even need it. I've been in 2 ER's where they drill just to get access to go to the OR for things like hip fx, optho cases
2. the research is in the US it's 24 hrs, europe/asia 72 hrs. not sure why our bones act differently across the ocean but that's what the rep told me at a conference 2 yrs ago
3. good question, I did one a few months ago. I guess you could numb the area up but he didn't complain. he described it as a sharp pencil sticking him. no pain with the drill either. only discomfort with the initial replacement of marrow and lidocaine first infusing. the pain went away after another lido bolus
4. I can only assume it's cheaper but i have no hard data

practice on eggs (not hard boiled) until you get the hang of it. they made us draw/drill in little smiley faces with the drill. it's that easy to use
contact your local rep and they'd be happy to send you a demo w needles to practice. then get the other docs on board for support to get your nurse manager/supply to order you one. also there are humeral (yellow needles) now approved for use. we don't have them yet but the flow rates are very impressive

 

[link2swim06]

1. How do you remove a IO line, and what care is needed for the IO site afterwards? I mean do you just pull the line, hold pressure, and put gauze and a bandaid?

I have removed one IO line and it was pretty easy. You just unscrew it like you would unscrew a screw stuck in wood.

Then I just threw a bandaid on it. I don't really remember a whole lot of pressure needing to be applied, however, this could vary based on location you placed it.

 

[erdoc00]

IO should primarily be used for rapid access when a quick peripheral IV cannot be placed. For this use, I think it is better than a central line. IO tends to be quicker and more reliable. I find this especially true in infants when very rapid access is needed for resuscitation. In most patients, there is no need (or time) for local anesthesia during insertion. (You can YouTube insertion of IOs into volunteers if you're curious.)

The biggest thing with insertion is to push the needle through the skin until it contacts bone and THEN begin using the drill to insert into the bone. Too many people "drill" through the skin. Once inserted, infuse 2-4cc of 1-2% Lidocaine (for an adult) through the IO so that it anesthetizes the underlying bone. Then you can infuse the appropriate meds (typically, if it can go through an IV, it can go through an IO).

For removal, twist the IO and pull it out. Then place a bandage. The reason 24 hours is the "limit" is in order to mitigate complications such as infection. The reality, too, is that after resuscitation has taken place, you should obtain a better method of access.

For more routine access, though, I would not place an IO. Non-emergent central lines would be far superior in nearly every regard. PICC access or US-guided peripheral IV would also work if you don't need the capabilities of a central line.

Make sure in your mind, though, that you realize IO and central line are not necessarily equivalent or interchangeable access techniques. Their usages (and advantages/disadvantages) are dependent on the situation and need.

 

[TooMuchResearch]

1. yep but I drilled someone in the ER, I'd leave it in until something else was placed. assuming they even need it. I've been in 2 ER's where they drill just to get access to go to the OR for things like hip fx, optho cases
2. the research is in the US it's 24 hrs, europe/asia 72 hrs. not sure why our bones act differently across the ocean but that's what the rep told me at a conference 2 yrs ago
3. good question, I did one a few months ago. I guess you could numb the area up but he didn't complain. he described it as a sharp pencil sticking him. no pain with the drill either. only discomfort with the initial replacement of marrow and lidocaine first infusing. the pain went away after another lido bolus
4. I can only assume it's cheaper but i have no hard data

practice on eggs (not hard boiled) until you get the hang of it. they made us draw/drill in little smiley faces with the drill. it's that easy to use
contact your local rep and they'd be happy to send you a demo w needles to practice. then get the other docs on board for support to get your nurse manager/supply to order you one. also there are humeral (yellow needles) now approved for use. we don't have them yet but the flow rates are very impressive

There was a study where they placed IOs in healthy college students and let them walk around with the things for weeks without any line infections. FDA still says "no way guys 24 hours."

 

[erdoc00]

There was a study where they placed IOs in healthy college students and let them walk around with the things for weeks without any line infections. FDA still says "no way guys 24 hours."

I don't know if healthy college students are representative of the groups most often requiring IOs. Also, in practice, I'm not sure of the scenario where an IO would be necessary for more than a few hours, let alone more than 24 hours.

 

[TooMuchResearch]

I don't know if healthy college students are representative of the groups most often requiring IOs. Also, in practice, I'm not sure of the scenario where an IO would be necessary for more than a few hours, let alone more than 24 hours.

It's proof of concept at minimum.

Our ICU leaves them in and uses them (fluids and pressors) until FDA says to pull them.

 

[da8s0859q]

1. How do you remove a IO line, and what care is needed for the IO site afterwards? I mean do you just pull the line, hold pressure, and put gauze and a bandaid?

2. My research says IO lines shouldn't really stay in for more than a day. So...

3. Would you provide any local analgesia first?

4. Any thoughts on the costs of a drill? It seems the drills are around $500 with educational sets around $800. How much are the needles themselves? And what is the cost of a central line kit? (To compare them.)

1. After we get solid access, many of our nurses pull the IO needle and apply a pressure wrap to the area. Seems the best approach to me.

2. What everyone else said. We don't leave ours in place long at all. Don't think I've heard of anyone even approaching 24 hours around here.

3. If I have the luxury of someone who can stand the slight delay for me to drum up some lidocaine for local anesthesia, sure, I'll numb them up. Vast majority -- as in 99% of the time -- no, because we generally IO people in whom we can't get, but really need, urgent or emergent vascular access before they get a CVC, and/or if there's too much going on around them to get a CVC placed... or an ultrasound-guided IV for that matter. It's quick. I'm not screwing around with local anesthesia when I'm worried about needing massive fluid resuscitation / peripheral pressor use pending a CVC / ACLS meds / etc.

4. Don't know what my hospital pays for various CVC kits. Have anecdotally heard that the needles run something like $100-$200 each, not sure.

I love IOs, but like others said, it's just a temporizing measure when you need something for vascular access. Easy to pop in an IO for an extra infusion site during initial stabilization, then get the central line in ASAP.