Intraosseous use

[Gern Blansten]

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Hypothetical scenario:

65 y/o male with DM type II for completely elective minor orthopedic procedure.
No IV access despite multiple attempts by the best in the hospital. Cancel the case?
-Would you have him return after PIC line placement? Seems overkill to do a PICC line for a 2 hour elective ortho case.
-would you utilize an intraosseous? Does the diabetes play a role in your decision?
-At what point do you consider an intraosseous line in an emergency? How bout in an elective case?
-Anybody out there using intraosseous fairly regularly?

Discuss.

 

[sevoflurane]

Hypothetical scenario:

65 y/o male with DM type II for completely elective minor orthopedic procedure.
No IV access despite multiple attempts by the best in the hospital. Cancel the case?
-Would you have him return after PIC line placement? Seems overkill to do a PICC line for a 2 hour elective ortho case.
-would you utilize an intraosseous? Does the diabetes play a role in your decision?
-At what point do you consider an intraosseous line in an emergency? How bout in an elective case?
-Anybody out there using intraosseous fairly regularly?

Discuss.

I would not place in IO line in a Diabetic patient for an elective ortho procedure (I'd be mainly worried about additional infection risk and Oh **** factor if you loose the line for whatever reason).

I'd put a PIV>AC>LE IV>EJ/IJ. I've placed an EJ in a dialysis patient in the outpatient setting, 2/2 difficult access.

I'm not sure how well IO's work in an adult. Never placed one.

One of the spine docs I work with went down to Haiti. 2 y/o michelin kid who was septic and in need of fluids urgently for ressucitation and abx. Kid was a difficult stick ontop of being severely dehydrated. 16 G IO. Worked like a charm and saved the kids life.

 

[Mac4]

I would be worried about infection and non-healing wounds on these diabetic patients.

 

[RxBoy]

Hypothetical scenario:

65 y/o male with DM type II for completely elective minor orthopedic procedure.
No IV access despite multiple attempts by the best in the hospital. Cancel the case?
-Would you have him return after PIC line placement? Seems overkill to do a PICC line for a 2 hour elective ortho case.
-would you utilize an intraosseous? Does the diabetes play a role in your decision?
-At what point do you consider an intraosseous line in an emergency? How bout in an elective case?
-Anybody out there using intraosseous fairly regularly?

Discuss.

IO is actually a pretty good line for emergencies in adults. I have used it about 10 times in the ED and trauma.

We use the EZ-IO's which are sweet http://www.vidacare.com/EZ-IO/Hospital-Clinical-Advantages.aspx

They are excellent for emergencies. But it would simply be a bridge until I had a more permanent line like a central. The only time I think I would use it in anesthesia is any unstable patient going to the OR (trauma, C/S, perforated bowel) with a very difficult stick. Most likely this will already be done in the ED.

These would be the contraindications:

• Fracture in targeted bone
• Previous orthopedic procedures near insertion site
• IO insertion in targeted bone within past 24 - 48 hours
• Infection at insertion site
• Inability to locate landmarks or excessive tissue

I would never use it for any elective case even though it would probably be OK. I would def opt for a EJ/IJ and if all fails send for IR IV placement.

As far as the IO line in adults, its kind of like a PICC. It barely drips if its only to gravity and under high pressure it drips a little faster. By no means is it a fluid line. Its good to give meds fast such as induction agents, ACLS meds, ect but thats about it.

 

[Gern Blansten]

Saw a similar scenario in an adult. Forgot to mention in hypothetical scenario, several EJ attempts unsuccessful and scheduled for upper extremity on one side, taking one UE out of the equation. Hypothetically done at an ASC. Not my hypothetical case. Just made me think of what options are out there. Case was elective, but DID need to be done.
I am also leery of IO in an elective scenario, especially in a diabetic. Anyone used a sternal IO?

 

[RxBoy]

Saw a similar scenario in an adult. Forgot to mention in hypothetical scenario, several EJ attempts unsuccessful and scheduled for upper extremity on one side, taking one UE out of the equation. Hypothetically done at an ASC. Not my hypothetical case. Just made me think of what options are out there. Case was elective, but DID need to be done.
I am also leery of IO in an elective scenario, especially in a diabetic. Anyone used a sternal IO?

I would still go for a central line, and again if all else fails.. IR PICC placement.

I am a firm believer in Murphy's law. **** always happens when I take a shortcut, too many examples to cite.

If you wing it with a IO, this will be the case the pt throws a massive PE.

 

[pgg]

I'd do an IJ before an IO line, especially if I wasn't in a hurry.

 

[Gern Blansten]

IO's are something I almost never use. Just wondering how often and in what situations people are using them. It sounds as though people's level of comfort is not that great with them at the current time except in emergencies.

Thanks for the feedback.

 

[dhb]

Saw a similar scenario in an adult. Forgot to mention in hypothetical scenario, several EJ attempts unsuccessful and scheduled for upper extremity on one side, taking one UE out of the equation.

If the arm to be operated on has potential access i would use that to put him under and get some vasodilation to switch the line. (actually did this last week)

 

[nap$ter]

IJ before IO.

put an IJ into a lady for dental extractions a few months ago.

h/o thorough, and i mean thorough IVDA - every vein was used - shoulders, breasts, feet, ej, forehead, fingers and thumbs. everyone tried for an hour (incl u/s) - no go.

conversation c dentist - teeth are infected, need to come out. can do it now, or in a month when she comes in with an obstructing abscess.

lady absolutely refuses local in her mouth - some issue with abuse/psych h/o... big fat IJ in her neck on u/s - she held still, threw it in, GA, teeth out, bandaid in pacu and d/c home.

 

[Gern Blansten]

IJ before IO.

put an IJ into a lady for dental extractions a few months ago.

h/o thorough, and i mean thorough IVDA - every vein was used - shoulders, breasts, feet, ej, forehead, fingers and thumbs. everyone tried for an hour (incl u/s) - no go.

conversation c dentist - teeth are infected, need to come out. can do it now, or in a month when she comes in with an obstructing abscess.

lady absolutely refuses local in her mouth - some issue with abuse/psych h/o... big fat IJ in her neck on u/s - she held still, threw it in, GA, teeth out, bandaid in pacu and d/c home.

Good case. You hate to do that, but sometimes there's not much choice.

 

[pgg]

IJ before IO.

put an IJ into a lady for dental extractions a few months ago.

h/o thorough, and i mean thorough IVDA - every vein was used - shoulders, breasts, feet, ej, forehead, fingers and thumbs. everyone tried for an hour (incl u/s) - no go.

conversation c dentist - teeth are infected, need to come out. can do it now, or in a month when she comes in with an obstructing abscess.

lady absolutely refuses local in her mouth - some issue with abuse/psych h/o... big fat IJ in her neck on u/s - she held still, threw it in, GA, teeth out, bandaid in pacu and d/c home.

Had an UE ortho case on Thursday. Cancer patient who'd had several PICCs, the last one removed just about two weeks prior. Multiple people, multiple attempts, no PIV. I tried a couple times, nothing. Even brought out the u/s and couldn't even find an AC. I was setting up for an IJ when one of our RNs got a 22 in a thumb vein.

 

[IlDestriero]

Had an UE ortho case on Thursday. Cancer patient who'd had several PICCs, the last one removed just about two weeks prior. Multiple people, multiple attempts, no PIV. I tried a couple times, nothing. Even brought out the u/s and couldn't even find an AC. I was setting up for an IJ when one of our RNs got a 22 in a thumb vein.

Don't discount the thumb vein. Been there many times.👍

 

[RT2MD]

Saw a similar scenario in an adult. Forgot to mention in hypothetical scenario, several EJ attempts unsuccessful and scheduled for upper extremity on one side, taking one UE out of the equation. Hypothetically done at an ASC. Not my hypothetical case. Just made me think of what options are out there. Case was elective, but DID need to be done.
I am also leery of IO in an elective scenario, especially in a diabetic. Anyone used a sternal IO?

The hospital where I used to work used IO a fair bit in the ED. I don't know about the OR, but I do know that the ED would send people to the floor for IO access during a code, if needed.

As far as sternal IO goes? Well, usually if we were putting in an IO, that person was pretty dang sick... if you throw a sternal IO in, you have lost your ability to do chest compressions. I realize that probably doesn't REALLY pertain to your case, but it could.... "Well... I can either give epi, or do compressions... which would you like?" 😀 I guess there would always be the option of giving drugs down the tube. (do people still even do that?) We would usually "shoot" for the tibial plateau, otherwise into the humerus.

I have seen a "radical cut down" IO placement. I don't think that was really the intended use of the IO, but this patient had a LOT of extra tissue and nobody could get access anywhere else. It was a disaster.

We also had a policy in place where the IO HAD to be discontinued after 24 hours... at least I think that was right. We strictly used it in emergent situations, and it needed to come out as soon as the patient was stabilized, in the unit, etc. We also would give a slug of abx with it.

With all that being said, my feeble M2 brain wouldn't think that doing an IO in your hypothetical case would be a good idea... but it would depend on how much risk there is without doing the case. Plus, what do I know?

-RT2MD

 

[Planktonmd]

Why can't you do chest compressions if you have a sternal IO?
The sternal IO should be inserted in the upper end of the sternum while the compressions are done on the lower end.

As far as sternal IO goes? Well, usually if we were putting in an IO, that person was pretty dang sick... if you throw a sternal IO in, you have lost your ability to do chest compressions.
-RT2MD

 

[michigangirl]

I've put in about 50 I/Os over the last six years in age range 0 days-25 y.o-- bottom line-- I/Os are only for real emergencies. They work great when they're successfully put in, but they are reserved for emergent situations so that you can get control of whatever horrible situation you're in and get some stable form of IV access-- and PIVs are much more stable than I/Os-- the caveat to I/Os in the OR are that they are fine while you can keep an eye on them. Once the drapes are up, all bets are off-- the chances of minimal dislodgement and infusing massive amounts of fluid into the wrong place and causing a compartment syndrome are not trivial. You need to keep a hand on the leg (or wherever) to make sure the fluid is going where it needs to be. Obviously in the little babies I often take care of it doesn't take much fluid in the wrong place to ruin a leg. But take a proportional amount of fluid in a big guy and you have the same problem.

I've used I/Os in the OR a couple times for young adolescent traumas where an IV induction is the only way to go in a screaming kid and you have NOTHING-- and hypotension to boot-- if you can work in some IM something or another obviously that is helpful from a discomfort standpoint. But I won't start the case until I have more secure access that I can count on while the drapes are up. I did have one case where I had to have the resident stationed by the leg under the drapes while we used the IO in order to make sure it was safe.

I agree with above-- this diabetic dude would not be an IO candidate.

 

[BobBarker]

I think it would be easier to use the ultrasound and a long catheter and place a poor man's PICC.

 

[RT2MD]

Why can't you do chest compressions if you have a sternal IO?
The sternal IO should be inserted in the upper end of the sternum while the compressions are done on the lower end.

Huh. Well, this was something that had been passed around the ED where I used to work. I just did a (very) quick lit search and did not find any evidence supporting my statement... I'll file that into the "don't believe everything that you hear" category. I suppose if there is enough "real estate" on a patient, there wouldn't be a problem. Have you had firsthand experience with this situation? I just always heard "we don't put sternal IOs in because it'd interfere with CPR".

Thanks!

 

[MTGas2B]

Huh. Well, this was something that had been passed around the ED where I used to work. I just did a (very) quick lit search and did not find any evidence supporting my statement... I'll file that into the "don't believe everything that you hear" category. I suppose if there is enough "real estate" on a patient, there wouldn't be a problem. Have you had firsthand experience with this situation? I just always heard "we don't put sternal IOs in because it'd interfere with CPR".

Thanks!

I've been a part of chest compressions with sternal IOs. The IO works. That was the least of our problems at the time.

 

[RxBoy]

Anyone use U/S and stick an IJ with a regular IV? Seen it done a couple of times by my attendings with a longer 18G catheter and aseptic technique.

Is this kosher?

 

[RT2MD]

I've been a part of chest compressions with sternal IOs. The IO works. That was the least of our problems at the time.

👍 Cool, thanks!

 

[Farmer2DO]

IO's are something I almost never use. Just wondering how often and in what situations people are using them.

As a paramedic, we use the EZ-IO gun in the field. We have the pediatric, adult and large adult needles, and all cardiac arrests get the IO before any peripheral attempts. We are approved to use the tibial route or the humeral head route. I've not done the humeral head, but my coworkers that have done them say they run better than the tibial lines. I've probably done a dozen tibial lines, and never had a problem with them.

Our company hates them, though, because Medicare (and thus everyone else) will only reimburse them at the rate of a peripheral IV. The gun is (I believe) $400, and each needle is $100, except the large adult, which is $140.

 

[Hamhock]

I've been a part of chest compressions with sternal IOs. The IO works. That was the least of our problems at the time.

Why sternal?

I have put in plenty of IOs and have never had to get to the sternum. I don't see the advantage and I see lots of disadvantages.

In most humans with arms and legs: prox tibia/humerus, then distal tibia, then femur.....then then sternum (but, haven't been there yet; and the talk of illiac)

Why sternal?

HH

 

[MTGas2B]

Why sternal?

In most humans with arms and legs: prox tibia/humerus, then distal tibia, then femur.....then then sternum (but, haven't been there yet; and the talk of illiac)

Why sternal?

HH

My patient's didn't always have these. We had asked our flight medics to get something in where ever they could. Beats nothing. Usually I'd just use it push some induction meds or epi, then slam a cortis in for the rest.

 

[MTGas2B]

So, I will mention a technique I've done before. IVDA type, no veins, can't hold still for a central line, has a big abscess somewhere that needs to be washed out. Low aspiration risk, not really "sick", not septic, etc. Mask induction with no access, slide in an LMA. Get central line in lickedy split.
I would not endorse this as your first option.
I would not use this answer on boards.
Residents, I would not suggest you offer this as your anesthetic plan to your staff.
I've only done it twice, things went fine. I'll be happy if I don't have to do it again.

 

[Hamhock]

My patient's didn't always have these. We had asked our flight medics to get something in where ever they could. Beats nothing. Usually I'd just use it push some induction meds or epi, then slam a cortis in for the rest.

Yeah - that's what I guessed - and that's why I added the "arms and legs" part.

Still, even with no arms and no legs, I don't think sternal I/O is my next option in most cases. I know it is discussed (esp in the world of EMS), but I can't think of a time I would go for it.

HH

 

[Arch Guillotti]

Anyone use U/S and stick an IJ with a regular IV? Seen it done a couple of times by my attendings with a longer 18G catheter and aseptic technique.

Is this kosher?

Depends on your definition of kosher.

I haven't done it but I know guys who have.

In an emergency with no IV access I would do it if I had no other options.

 

[Arch Guillotti]

I think it would be easier to use the ultrasound and a long catheter and place a poor man's PICC.

This is a great technique that I think is vastly underutilized. it isn't always a slam dunk though.

 

[michigangirl]

Anyone use U/S and stick an IJ with a regular IV? Seen it done a couple of times by my attendings with a longer 18G catheter and aseptic technique.

Is this kosher?

If the patient is dying-- then yes-- but then I would argue it's time for an I/O---I'm just gonna assume they already tried an EJ. If you were doing an IJ, that better be a mega long catheter. I would worry a lot about it becoming even slightly dislodged/coming out of the vessel and infusing fluid into the neck. Only kosher in a moment of desperation. And even then, doesn't sound so kosher. Might as well take the extra minute and do a quickie drape, stick wire, thread catheter.

 

[sevoflurane]

If the patient is dying-- then yes-- but then I would argue it's time for an I/O---I'm just gonna assume they already tried an EJ. If you were doing an IJ, that better be a mega long catheter. I would worry a lot about it becoming even slightly dislodged/coming out of the vessel and infusing fluid into the neck. Only kosher in a moment of desperation. And even then, doesn't sound so kosher. Might as well take the extra minute and do a quickie drape, stick wire, thread catheter.

This is good advice. I do it rarely and only when I have to.... and even then, I'm skeptical and unhappy especially if I have a short catheter in a neck vessel. I've had one infiltrate on me despite good initial placement. Fortunately, I picked it up early. I just don't trust them for longer cases and inpatients.

As Michgirl said, you need a long catheter as neck movement by the patient can cause the tip of the IV to end up outside of the vessel. They do make long angiocaths, but you might as well put something a little more definitive and take it out once you don't need it. Just saves you potential headaches, IMO.

 

[pgg]

If you were doing an IJ, that better be a mega long catheter. I would worry a lot about it becoming even slightly dislodged/coming out of the vessel and infusing fluid into the neck.

This is good advice. I do it rarely and only when I have to.... and even then, I'm skeptical and unhappy especially if I have a short catheter in a neck vessel. I've had one infiltrate on me despite good initial placement. Fortunately, I picked it up early. I just don't trust them for longer cases and inpatients.

I once injected an induction dose of propofol through a neck IV that went bad. For the next day or two I sweated what a subcutaneous pocket of the white stuff would do in a septic patient. Turned out, nothing. Still, I learned to fear angiocaths in fat necks.

 

[C.P.]

IO's are an invaluable tool. Like any tool, you need to know when to use them.
tibial or humeral head are usually the easiest to site and stabilize.
I can't comment on sternal IO lines (I'm no I-O master, but to be honest, I didn't even know they could be placed in the sternum).

We had a tough run of ICU residents/fellows trying to place femoral central lines in a coding patient while compressions were going on, with a wide range of poor successes or just weird outcomes, so now have a policy that a patient under CPR that needs rapid IV access is to receive on IO.

They aren't that technically challenging to place.
They're bloody expensive, so don't use them unless it really is an emergency.
AND . . . THEY HURT LIKE CRAZY!!!
Not on insertion, but on initial infusion.
I didn't realize this till someone decided their non-responsive ICU patient needed rapid IV Narcan.
Tibial IO goes in. . . patient doesn't budge. IO infusion starts, patient hits the ceiling and starts screaming (she was post op, had some narcs on board, and took her hearing aide out. . . hence part of the lack of response).

Use an IO if you need it, they can be life savers, but make sure the patient's either sedated or is dead and needs to get rapidly better.

 

[michigangirl]

IO's are an invaluable tool. Like any tool, you need to know when to use them.
tibial or humeral head are usually the easiest to site and stabilize.
I can't comment on sternal IO lines (I'm no I-O master, but to be honest, I didn't even know they could be placed in the sternum).

We had a tough run of ICU residents/fellows trying to place femoral central lines in a coding patient while compressions were going on, with a wide range of poor successes or just weird outcomes, so now have a policy that a patient under CPR that needs rapid IV access is to receive on IO.

They aren't that technically challenging to place.
They're bloody expensive, so don't use them unless it really is an emergency.
AND . . . THEY HURT LIKE CRAZY!!!
Not on insertion, but on initial infusion.
I didn't realize this till someone decided their non-responsive ICU patient needed rapid IV Narcan.
Tibial IO goes in. . . patient doesn't budge. IO infusion starts, patient hits the ceiling and starts screaming (she was post op, had some narcs on board, and took her hearing aide out. . . hence part of the lack of response).

Use an IO if you need it, they can be life savers, but make sure the patient's either sedated or is dead and needs to get rapidly better.

It seems much more likely to me that she was having the typical freak out one gets when they are on narcs and the rapid IV narcan actually hits!

 

[imfrankie]

I kind of got sold on the utility of the EZ-IO a few years ago, though I haven't used it. There are lotsa YouTubes in volunteers of how painless and EZ it is. "Zip-zip, gee whiz that didn't hurt at all pa!" The manufacturers market it as extreme low risk, used all the time by the military, etc. I'd love to see some literature that supports the safety of its use in these difficult access situations that aren't complete Hail Mary's. If none exists, would be a nice study and potentially very helpful to know if we could feel comfortable popping these in more liberally. Peter Davis brought this up at an SPA meeting a few years ago in an audience questionnaire/discussion.

 

[michigangirl]

I kind of got sold on the utility of the EZ-IO a few years ago, though I haven't used it. There are lotsa YouTubes in volunteers of how painless and EZ it is. "Zip-zip, gee whiz that didn't hurt at all pa!" The manufacturers market it as extreme low risk, used all the time by the military, etc. I'd love to see some literature that supports the safety of its use in these difficult access situations that aren't complete Hail Mary's. If none exists, would be a nice study and potentially very helpful to know if we could feel comfortable popping these in more liberally. Peter Davis brought this up at an SPA meeting a few years ago in an audience questionnaire/discussion.

I LOVE the EZ I-O-- we have had it in tiny to adult sizes for the past year in the both the PICU and ED. It's seamless. We take it on all of our pediatric critical care transports, where it has come in VERY useful.

 

[ATeam2012]

Just sat through a lecture and skills workshop on EZIO given by Dr Larry Miller himself. Such an awesome and positive guy.

 

[ATeam2012]

I kind of got sold on the utility of the EZ-IO a few years ago, though I haven't used it. There are lotsa YouTubes in volunteers of how painless and EZ it is. "Zip-zip, gee whiz that didn't hurt at all pa!" The manufacturers market it as extreme low risk, used all the time by the military, etc. I'd love to see some literature that supports the safety of its use in these difficult access situations that aren't complete Hail Mary's. If none exists, would be a nice study and potentially very helpful to know if we could feel comfortable popping these in more liberally. Peter Davis brought this up at an SPA meeting a few years ago in an audience questionnaire/discussion.

So according to Dr Miller there's a physician named mark Walsh who has been practicing in Haiti who uses EZIO a lot and will be coming out with a paper on risks and effects among other things. Also quoting from Larry Miller (founder/inventor of Vidacare/EZIO) there has been one documented infectious complication out of one million recorded cases.



.

 

[Gern Blansten]

Good overall discussion. Thanks to all for the input.

 

[Jay K]

Anyone use U/S and stick an IJ with a regular IV? Seen it done a couple of times by my attendings with a longer 18G catheter and aseptic technique.

Is this kosher?

Have seen this once sans u/s; Beggars can't be choosers in the worst of situations. Tucked that experience into a back pocket.