Adult coding without vascular access: "dirty" femoral central line, or IO?

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Emergent access of choice when IV access predicted to be difficult/unsuccessful?

  • Intraosseous

    Votes: 39 75.0%

  • Femoral central venous access

    Votes: 12 23.1%

  • Other

    Votes: 1 1.9%
  • Total voters
    52
R

RPedigo

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If a patient rolls in coding and has no vascular access (and let's say that IV access is predicted to be difficult), what is your emergent access of choice between the common femoral central line and intraosseous placement? The "dirty" femoral line has to come out within 24 hours, is more time consuming, and associated with more complications than IO placement. However, IO placement also has to come out within 24 hours but of course will have much slower infusion rates than an introducer catheter (but perhaps not slower than each lumen of a central line), but multiple can be placed.

I see a lot of femoral lines placed in these situations, but in the time it takes to get everything ready for a central line, the patient could have bilateral medial tibial 15-gauge IOs placed. Once things settle down, a sterile high line could be placed afterward and the IOs removed. What are everyone else's thoughts on this?
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RPedigo said:
If a patient rolls in coding and has no vascular access (and let's say that IV access is predicted to be difficult), what is your emergent access of choice between the common femoral central line and intraosseous placement? The "dirty" femoral line has to come out within 24 hours, is more time consuming, and associated with more complications than IO placement. However, IO placement also has to come out within 24 hours but of course will have much slower infusion rates than an introducer catheter (but perhaps not slower than each lumen of a central line), but multiple can be placed.

I see a lot of femoral lines placed in these situations, but in the time it takes to get everything ready for a central line, the patient could have bilateral medial tibial 15-gauge IOs placed. Once things settle down, a sterile high line could be placed afterward and the IOs removed. What are everyone else's thoughts on this?
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If you really need quick access, there is NOTHING that beats an IO. Presuming you have the equipment ready it can be placed in less than 1 minute. Even the quickest Fem line is likely to take 2-3 minutes.
 
GeneralVeers said:
If you really need quick access, there is NOTHING that beats an IO. Presuming you have the equipment ready it can be placed in less than 1 minute. Even the quickest Fem line is likely to take 2-3 minutes.
Click to expand...

On that note, are there any conditions in which you feel a femoral central line ever needs to be placed? What about a saphenous vein cutdown? I seems that IO can/has largely replaced these procedures.
 
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RPedigo said:
If a patient rolls in coding and has no vascular access (and let's say that IV access is predicted to be difficult), what is your emergent access of choice between the common femoral central line and intraosseous placement? The "dirty" femoral line has to come out within 24 hours, is more time consuming, and associated with more complications than IO placement. However, IO placement also has to come out within 24 hours but of course will have much slower infusion rates than an introducer catheter (but perhaps not slower than each lumen of a central line), but multiple can be placed.

I see a lot of femoral lines placed in these situations, but in the time it takes to get everything ready for a central line, the patient could have bilateral medial tibial 15-gauge IOs placed. Once things settle down, a sterile high line could be placed afterward and the IOs removed. What are everyone else's thoughts on this?
Click to expand...

This somewhat depends on the institution & what people are comfortable with.

Whatever goes fastest in your ED. I like doing both simultaneously, in case the IO fails or is dislodged; and the multiport quad lumen has a lot of advantages.

Cheers!
-d

Sent from my DROID BIONIC using Tapatalk
 
RPedigo said:
On that note, are there any conditions in which you feel a femoral central line ever needs to be placed? What about a saphenous vein cutdown? I seems that IO can/has largely replaced these procedures.
Click to expand...

When I had to recert ATLS for my current job (a separate issue), the 4th yr surgery resident doing the access portion of the skills lab talked about how a saphenous cutdown at the level of the inguinal ligament was their access of choice for difficult sticks. He also mentioned that they routinely pulled out and threw away IOs on patients that had them placed in the field. There are people that have blown through their vascular access up to, so I wouldn't say that a femoral CVL has no indication, it's just not first line in a coding patient.
 
southerndoc said:
I can put in a femoral quad lumen in about a minute. Our central lines are in the code room, the IO's aren't (because the drill needs to be kept at the central command area to keep from it "walking off").
Click to expand...

I can do it under a minute too. In the right conditions. But the 40% or so with abnormal anatomy, or veins so flat you never get a flash I feel like I can never get them.
So I agree with trying both. I don't have to put in the IO. Any medic/nurse can. They can't start the CVL.

I don't usually do quads during resus though. Just the cordis. I can always wire it out later if they need more ports. Or do the dirty ICU technique of slipping a triple lumen down the port of an introducer.
 
Depends on how many docs (?residents or solo) are available.

Preferred: both simultaneously.

I am rarely alone in a resus (I only work at residency sites), but if I did I would place a quick IO, then Cordis vs. TLC.

HH
 
RPedigo said:
On that note, are there any conditions in which you feel a femoral central line ever needs to be placed? What about a saphenous vein cutdown? I seems that IO can/has largely replaced these procedures.
Click to expand...

Had a case of bilateral AKA the other day. Attempts at bilateral humeral IOs (yellows) both were dislodged...had to place a central line.

HH
 
IO if available. Then, hope someone can get a peripheral quickly. If no luck then I am likely putting in CVC while the rest of the code runs because one access point is not enough.
 
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Had this situation last night and went two immediate IOs (longest part was taking it out of the package), then did the hyperK treatment/fluids/pacing and stabilized enough to put in a subclavian once we got pulses back
 
I agree that the IO is the access of choice in that situation. But there are instances where the IO is a problem. Patients with no legs or with severe edema or obesity present an obstacle. Most of us are not as confident placing a humeral IO as we are a tibial IO and then the landmarks can be tricky especially in the setting of obesity, edema, etc. I also run into patients that have had multiple attempts by EMS so the site(s) are unusable.

In those situations I would go back to a fem line quick and dirty. If the patient survived I'd likely then place an IJ with sterile technique after the dust settles.
 
Hard stick coding? IO first. Gets you some access. This is of course if it's not some morbidly obeese person with horrible landmarks. I have done humeral in addition to tibial. Haven't done a sternal like some of the army medics out there have.

Once the IO is placed, I try to pop in a quik femoral line. The beauty of this is chest compressions can keep going while your trying to do this unless a panus is flopping in your way which makes thing more itneresting lol :laugh: . An IJ is another site you can go for but femoral is still my fastest site. The only way I can see the IJ being quicker in an emergency is if you go for it blind.

When the guy is coding, the risks of line related infection because you chose a femoral site should be the last thing on your mind.
 
Cerberus said:
My post-shift reading comprehension is 1-2 words per sentence. It's the end result of trying to find something useful in triage and nursing notes all day.
Click to expand...

It's spelled "pneumonia"!
 
Emergent code?

I'd use an IO as I just can't do anything faster. If I can't get it in the tibia due to obesity, etc.. then I'd put it in the sternum.

CVL later... My reasoning is that IO access is a much faster way to gain venous access for code drugs/resuscitation and has a higher chance of first time success. The femoral CVL in a pulseless patient has the potential to tie me up due to unforeseen complications albeit low probability... There's plenty of data that actually shows the "palpable pulse" felt during compressions is actually venous, not arterial when palpating the groin. Don't get me wrong... I think we could all shove it in a vessel lightning fast, but my first reflex would probably be to reach for the IO while their bagging/compressions and then definitively take care of airway while I run the code, then switch to the CVL if appropriate. That's assuming I don't have 20 people standing around to help.
 
Not even in a coding pt, but sick dialysis pts...I am very reluctant to throw a high line in these folks. I know it's shown to be safe...but I'm not gonna be the schlock who thromboses their high vein ;^)
 
docB said:
I agree that the IO is the access of choice in that situation. But there are instances where the IO is a problem. Patients with no legs or with severe edema or obesity present an obstacle. Most of us are not as confident placing a humeral IO as we are a tibial IO and then the landmarks can be tricky especially in the setting of obesity, edema, etc. I also run into patients that have had multiple attempts by EMS so the site(s) are unusable.

In those situations I would go back to a fem line quick and dirty. If the patient survived I'd likely then place an IJ with sterile technique after the dust settles.
Click to expand...

EZ-IO now has a bariatric size needle which seems to work well to eliminate the previous problem with obese patients.

As far as alternative sites, I would avoid the sternal site as someone mentioned above. It is associated with higher complication rate and also gets in the way of compressions and other patient care activities. If you do not want to use the tibia or the humerus for some reason, the iliac crest is also a possible site of insertion. I'm not sure the actual statistics but it seems the amount of patients you could not get access on when utilizing tibia, humerus, and iliac crest would be extremely small.
 
joeDO2 said:
EZ-IO now has a bariatric size needle which seems to work well to eliminate the previous problem with obese patients.

As far as alternative sites, I would avoid the sternal site as someone mentioned above. It is associated with higher complication rate and also gets in the way of compressions and other patient care activities. If you do not want to use the tibia or the humerus for some reason, the iliac crest is also a possible site of insertion. I'm not sure the actual statistics but it seems the amount of patients you could not get access on when utilizing tibia, humerus, and iliac crest would be extremely small.
Click to expand...

I've seen the bariatric needles although we don't have any in the ED. I suspect that the failure rate and complication rate both go up with those as you're shooting at a target that's farther away.
 
joeDO2 said:
EZ-IO now has a bariatric size needle which seems to work well to eliminate the previous problem with obese patients.

As far as alternative sites, I would avoid the sternal site as someone mentioned above. It is associated with higher complication rate and also gets in the way of compressions and other patient care activities. If you do not want to use the tibia or the humerus for some reason, the iliac crest is also a possible site of insertion. I'm not sure the actual statistics but it seems the amount of patients you could not get access on when utilizing tibia, humerus, and iliac crest would be extremely small.
Click to expand...

There's no such study that I'm aware of, so post it if you have read one because I'd be very curious...

It is a valid alternative site for IO access and more easily obtainable with no extra positioning required after Tibia failure, unlike humerus. There are plenty of IO's marketed as sternal only IO's like the FAST1 and the latest article I read from 2011 was about a 75% success rate in pre-hospital setting with a paramedic placing one in a bouncing ambulance. Not too shabby. It's also placed in the upper sternum and therefore does not interfere with compressions and if you've placed many IO's, they don't exactly shake loose very easily or "slip out" like an angiocath from a vein.

Also, there's a study that I'm too lazy to look up on animal models comparing all IO's with time to peak concentration of code drugs and sternal IO is the fastest with Tibia taking roughly twice as long to obtain peak arterial concentration.

It ain't the first place you're going to go for, but don't let pre-conceived notions and subjective opinion get in the way of a potentially very useful way to facilitate rapid venous access in a critical patient.

The latest studies for 1st time IO success, and I'll post them if people are interested but it's roughly:

1) Tibia: ~86%
2) Humerus: ~60%
3) Sternum: ~75%

All pre-hospital retrospective studies. Don't knock the sternum.

I've seen very few people do sternal IO's simply because most people don't know much about them or haven't done one before, not because it's been clinically proven to be a terrible site. It hasn't.
 
Groove said:
There's no such study that I'm aware of, so post it if you have read one because I'd be very curious...

It is a valid alternative site for IO access and more easily obtainable with no extra positioning required after Tibia failure, unlike humerus. There are plenty of IO's marketed as sternal only IO's like the FAST1 and the latest article I read from 2011 was about a 75% success rate in pre-hospital setting with a paramedic placing one in a bouncing ambulance. Not too shabby. It's also placed in the upper sternum and therefore does not interfere with compressions and if you've placed many IO's, they don't exactly shake loose very easily or "slip out" like an angiocath from a vein.

Also, there's a study that I'm too lazy to look up on animal models comparing all IO's with time to peak concentration of code drugs and sternal IO is the fastest with Tibia taking roughly twice as long to obtain peak arterial concentration.

It ain't the first place you're going to go for, but don't let pre-conceived notions and subjective opinion get in the way of a potentially very useful way to facilitate rapid venous access in a critical patient.

The latest studies for 1st time IO success, and I'll post them if people are interested but it's roughly:

1) Tibia: ~86%
2) Humerus: ~60%
3) Sternum: ~75%

All pre-hospital retrospective studies. Don't knock the sternum.

I've seen very few people do sternal IO's simply because most people don't know much about them or haven't done one before, not because it's been clinically proven to be a terrible site. It hasn't.
Click to expand...

I wouldn't say that it is a terrible site, I would just make it my 4th choice and its not often you have to get to the 4th option. It seems that there is always a lot going on at that area of the patient and adding your IV/med person would crowd an overcrowded area already.

"Intraosseous vascular access in adults using the EZ-IO in an emergency department"
Int J Emergency Medicine Sept 2009

"Various site have been proposed as suitable for IO insertions, including the proximal tibia [3, 4, 13], distal tibia [2], sternum [4, 12, 13, 22], radius [32], clavicle [14], proximal humerus and calcaneum [33]. The proximal tibia and proximal humerus sites were chosen for this study. The proximal tibia site was the initial insertion site of choice, as the landmarks were easily identifiable, superficial, easy to access percutaneously and proximal enough to allow rapid access of fluids or medications into the central circulation. In addition, it is away from vital areas where other resuscitation procedures are ongoing as well as vital structures that might get inadvertently punctured during insertion. For example, the sternal and clavicular sites present problems when airway procedures and cervical immobilization are ongoing in trauma resuscitation. Likewise, the investigators felt that the distal tibia, radius and calcaneum sites would be relatively distal to the central circulation. The proximal humerus was the secondary site, in the event that intravenous cannulation was still unsuccessful after initial resuscitation."

The full article is that this was taken from can be accessed here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2760700/

The sternal route if using the FAST device also tends to be longer than other methods:
From UpToDate:
"Available evidence indicates the following overall success rates and time to IO insertion in children and adults undergoing resuscitation:
Manual needles: 76 to 100 percent (50 to 67 percent in patients over one year of age) [22,49-51], median time to insertion 38 seconds [50]
Battery-powered driver: 87 to 97 percent [30,52,53], median time to insertion <10 seconds [30]
Bone injection gun: 45 to 91 percent [50,54-56], median time to insertion 49 seconds [50]
FAST1®: 72 to 95 percent [50,53,57], median time to insertion 62 seconds [50]"

Also noted was that the only deaths ever recorded from IO insertion were due to mediastinitis, hydrothorax, and great vessel injury from the sternal site.

Again, not completely against it but just think there are many better sites.
 
Last edited:
Pharmacokinetics of intraosseous and central venous drug delivery during cardiopulmonary resuscitation.

CONCLUSIONS:
IO drug administrations via either the sternum or tibia were effective during CPR in anesthetized swine. However, IO drug administration via the sternum was significantly faster and delivered a larger dose.

Evaluation of success rate and access time for an adult sternal intraosseous device deployed in the prehospital setting.

(Thirty (73%) of these were placed successfully. The mean time to successful placement was 67 seconds for 28 attempts)

CONCLUSION:
This is the first study to prospectively evaluate the prehospital use of the FAST-1 sternal IO as a first-line device to obtain vascular access in the critically ill or injured patient. The FAST-1 sternal IO device can be a valuable tool in the paramedic arsenal for the treatment of the critically ill or injured patient. The device may be of particular interest to specialty disaster teams that deploy in austere environments.


Comparison of first-attempt success between tibial and humeral intraosseous insertions during out-of-hospital cardiac arrest.

The rate of first-time IO success at the tibia was significantly higher than that observed at the humerus (89.7% vs. 60.0%; p < 0.01). There were 18 initial successes at the humerus; for six (33.3%) of these, the needle became dislodged during resuscitation, compared with 52 initial successes at the tibia, with three (5.8%) dislodgments. The rate of total success for initial IO placements was significantly lower for the humerus (40.0%) compared with that for the tibia (84.5%; p < 0.01) during resuscitation efforts. CONCLUSIONS:
In this subset of patients, tibial IO needle placement appeared to be a more effective insertion site than the proximal humerus. Success rates were higher with a lower incidence of needle dislodgments. Further randomized studies are required in order to validate these results

Evaluation of success rate and access time for an adult sternal intraosseous device deployed in the prehospital setting.

CONCLUSION:
This is the first study to prospectively evaluate the prehospital use of the FAST-1 sternal IO as a first-line device to obtain vascular access in the critically ill or injured patient. The FAST-1 sternal IO device can be a valuable tool in the paramedic arsenal for the treatment of the critically ill or injured patient. The device may be of particular interest to specialty disaster teams that deploy in austere environments.

You're in med school. Reading and interpreting journal articles and studies is a ball of wax all unto itself. "Uptodate" is not always "up to date". EZ-IO is "EZ" and "fast"-er than FAST-1 sternal IO because...well...it's got a battery powered driver/drill. That's like comparing a hammer to a nail gun. Also, success rates differ depending on who's doing it. Paramedic? Pre-hospital setting or ED? (i.e. bumpy ride at 80mph down interstate 90 with medic or lying on a stretcher in the trauma bay with ED doc?) Either way, as far as IO's go... Tibia should always be first choice.

The one death or incidental mediastinitis doesn't particularly impress me... After all, the last thing I'm really worried about in a pulseless patient where emergent venous access is required...is mediastinitis.

Anyway, there's some links to read over. As I said, there's no study definitively concluding sternal IO with higher complication rates. We barely have a handful of studies on them already.
 
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Groove said:
You're in med school. Reading and interpreting journal articles and studies is a ball of wax all unto itself.
Click to expand...

ouch! Well I'm not looking to make a big argument over it. I agree there is not definitive evidence against it. Admittedly I have not placed a sternal IO personally. The sternal site was not allowed by protocol with the reason given to us being the increased complication rate ( I will see if this was based on some data or anecdotal info by med directors). My opinion on the matter stands however that even if complication rates are similar, it is the least convenient location. Having lead many codes and placed an IO on every one (1st line access by protocol), it seems that the upper chest area around the patient is crowded enough and the other sites are more away from the rest of the action. Thanks for posting those articles though. It does seem to be getting some increased attention lately so I'm interested to see how it plays out.
 
I remember reading an article which compared IO flow rates to their equivalent IV size in a peripheral vein.

Tibial IO = 22 g

humeral = 20 g

sternal = 18 g

I agree about a sternal IO possible getting in the way of compressions in the imminently coding patient. Never done a sternal personally. Between tibal/ humeral sites, I have never been in the situation of a patient about to code where I couldn't get IO access or do a cut down.
 
There's no doubt in my mind that if I have an I/O on my right and a central line kit on my left, the I/O is faster.

BUT...

- We don't keep our I/O drills handy. They're locked up in some cabinet, so no one walks off with them (just like someone else mentioned).

- I can have a DIRTY (and I mean sterile gloves, a quick chloroprep, and that's it) femoral put in in the time it takes someone to walk over to the cabinet, fidget with the lock a few times, unlock it, grab the case, bring it back to the resus room, and hand it to me.

PLUS

- I can grab all the bloodwork I want off that line, before I flush it, including an iStat

AND

If the guy makes it, I can start multiple drips (fluids, pressors, etc) with a triple lumen that I can't do with an I/O.

So my first instinct is still to go for the CVL.
 
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