IO for difficult IV access?

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2Fast2Des

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Anyone do IO's for patients with known difficult access to get something for induction and get PIVs once asleep? Was wondering if this is a possibility for the patients with teeny tiny veins or no veins rather than poking holes everywhere and wasting time
 
My question then is why not? Doesn't have to be a routine thing, just another tool in the shed
 
As an old rusty tool in the shed that I use once the world ends to hack off zombies. Sure.

But the benefit/risk ratio almost never beat US guided IV placement. Also the image/reputation of having to drill bone before you induce someone makes it a nuclear option.
 
If you can’t get a peripheral IV with even u/s just place a cvl. The complication rate of an u/s guided IJ cvl in competent hand has got to be near 0.
 
2Fast2Des said:
Anyone do IO's for patients with known difficult access to get something for induction and get PIVs once asleep? Was wondering if this is a possibility for the patients with teeny tiny veins or no veins rather than poking holes everywhere and wasting time
Click to expand...

Can u do a mask induction? Dilate those veins and place the iv then?
 
2Fast2Des said:
Anyone do IO's for patients with known difficult access to get something for induction and get PIVs once asleep? Was wondering if this is a possibility for the patients with teeny tiny veins or no veins rather than poking holes everywhere and wasting time
Click to expand...

LOL, an IO for an elective induction? Are you ****ting me? No elective case should be getting elective access where the complications theoretically include fracture, deep hematoma, fat emboli, and compartment syndrome. Even a CVL under U/S in experienced hands is preferable to an IO, but hopefully this can be avoided too.

If you can't find a vein with U/S in the AC, put a tourniquet on right at the armpit crease. Lay the patient's arm out like you were doing an axillary block. In 99.999% of patients you will see a juicy axillary vein right below the tourniquet, or if you go a bit distal and scan around there will be either a decent basilic, brachial, or cephalic vein. Use a 12cm 20g arrow, micropuncture, or argon kit and use seldinger. Takes 5 minutes.
 
vector2 said:
LOL, an IO for an elective induction? Are you ****ting me? No elective case should be getting elective access where the complications theoretically include fracture, deep hematoma, fat emboli, and compartment syndrome. Even a CVL under U/S in experienced hands is preferable to an IO, but hopefully this can be avoided too.

If you can't find a vein with U/S in the AC, put a tourniquet on right at the armpit crease. Lay the patient's arm out like you were doing an axillary block. In 99.999% of patients you will see a juicy axillary vein right below the tourniquet, or if you go a bit distal and scan around there will be either a decent basilic, brachial, or cephalic vein. Use a 12cm 20g arrow, micropuncture, or argon kit and use seldinger. Takes 5 minutes.
Click to expand...

I guess I should have been more specific of patient population, I was thinking in my head more along the line of the poked a million times, ESRD with fistulas everywhere kind of deal. I'm not advocating this for every case lol, just as a back up measure to consider. Yes mask induction is always possibility.
 
2Fast2Des said:
I guess I should have been more specific of patient population, I was thinking in my head more along the line of the poked a million times, ESRD with fistulas everywhere kind of deal. I'm not advocating this for every case lol, just as a back up measure to consider. Yes mask induction is always possibility.
Click to expand...

I have yet to encounter a patient that could not have some sort of IV access established prior to starting an elective case. Less than once a year I will have to start a central line in preop holding. I'd rather do that than an IO.
 
Side q: how many IOs have your guys done? Baby or adult?

I admit none.
 
We often get babies in the ER who've had IO's placed prior to arrival. They are usually garbage. I remember when the ER wanted anesthesia backup for an airway one time and they pushed all the drugs through the IO line. 3 minutes after the Roc the kid is still breathing and they are all looking at each other like what could possibly be going on? I asked if they had other access and of course they neglected to mention the PIV. 🙁
 
Mman said:
I have yet to encounter a patient that could not have some sort of IV access established prior to starting an elective case. Less than once a year I will have to start a central line in preop holding. I'd rather do that than an IO.
Click to expand...

What about patients with special needs?
 
2Fast2Des said:
I was thinking in my head more along the line of the poked a million times, ESRD with fistulas everywhere kind of deal.
Click to expand...

This is a great time to bring this up:

Use the fistula.

Have you ever spoken to a vascular surgeon about why they won't let anyone use the fistula?? I got curious and chatted one up once: they want to extend the life of the fistula by minimizing people screwing it up. In the same conversation, he explicitly gave me (anes as a specialty) to use it:

"You guys place more and better IV than anyone and i don't think there is a group of people that's more qualified to take care of it. You prob can easily take care of it better than the dialysis nurses."

He also cited 0 concern about paradoxical emboli or infection risk. Therefore, I would not hesitate to place a 24 G and induce with any working fistula. (Or just attach a small needle in line and use it only to induce)


They can use it to exchange liters of blood but we have to poke them 30times to give them 30ccs of induction drugs??
 
Last edited:
dchz said:
This is a great time to bring this up:

Use the fistula.

Have you ever spoken to a vascular surgeon about why they won't let anyone use the fistula?? I got curious and chatted one up once: they want to extend the life of the fistula by minimizing people screwing it up. In the same conversation, he explicitly gave me (anes as a specialty) to use it:

"You guys place more and better IV than anyone and i don't think there is a group of people that's more qualified to take care of it. You prob can easily take care of it better than the dialysis nurses."

He also cited 0 concern about paradoxical emboli or infection risk. Therefore, I would not hesitate to place a 24 G and induce with any working fistula. (Or just attach a small needle in line and use it only to induce)


They can use it to exchange liters of blood but we have to poke them 30times to give them 30ccs of induction drugs??
Click to expand...

I think the “problems” using fistula is also resistance from the patient themselves. They probably have been “taught” by the power that be, the only people who can ever use it is the dialysis nurses. Also I am sure OR nurses had the same education programming. I would not be surprised one of their eyes pop out if I try to do this.
I am surprised no one suggested EJ? Thrombosis?
 
IMGASMD said:
I think the “problems” using fistula is also resistance from the patient themselves. They probably have been “taught” by the power that be, the only people who can ever use it is the dialysis nurses. Also I am sure OR nurses had the same education programming. I would not be surprised one of their eyes pop out if I try to do this.
I am surprised no one suggested EJ? Thrombosis?
Click to expand...

The last few EJ's I tried were horrible. If you have someone who hates getting stuck because people keeping missing their veins, they're 10 times worse when you try to stick it in their neck. The last guy I tried it on was a IVDU for 10 years, terrible veins and he screamed bloody murder when I popped the plastic top off the iv. It was insanity.
 
Psai said:
The last guy I tried it on was a IVDU for 10 years, terrible veins and he screamed bloody murder when I popped the plastic top off the iv. It was insanity.
Click to expand...

I had a IVDU tell me to follow the tracks into their EJ. Worked like a charm. And I can't believe someone that has been shooting up for 10+ years is afraid of a needle stick. They are just putting on a show at that point.
 
Mman said:
I had a IVDU tell me to follow the tracks into their EJ. Worked like a charm. And I can't believe someone that has been shooting up for 10+ years is afraid of a needle stick. They are just putting on a show at that point.
Click to expand...

It’s too close to his neck, and he’s afraid of needle... /s
 
dchz said:
This is a great time to bring this up:

Use the fistula.

Have you ever spoken to a vascular surgeon about why they won't let anyone use the fistula?? I got curious and chatted one up once: they want to extend the life of the fistula by minimizing people screwing it up. In the same conversation, he explicitly gave me (anes as a specialty) to use it:

"You guys place more and better IV than anyone and i don't think there is a group of people that's more qualified to take care of it. You prob can easily take care of it better than the dialysis nurses."

He also cited 0 concern about paradoxical emboli or infection risk. Therefore, I would not hesitate to place a 24 G and induce with any working fistula. (Or just attach a small needle in line and use it only to induce)


They can use it to exchange liters of blood but we have to poke them 30times to give them 30ccs of induction drugs??
Click to expand...

Yea people keep forgetting this one.
I think it may be also due to lack of experience. I guess you just have to put the needle anywhere in that giant lump of fistula. I've never done it but when we take it out, is it just compression of the entire fistula near the puncture site? I'm sure no PACU nurse will touch it if i go to PACu with IV in the fistula.. And also would it back up in the IV tubing? May need pressure bag?
 
2Fast2Des said:
I guess I should have been more specific of patient population, I was thinking in my head more along the line of the poked a million times, ESRD with fistulas everywhere kind of deal. I'm not advocating this for every case lol, just as a back up measure to consider. Yes mask induction is always possibility.
Click to expand...

~30% of my patient population is ESRD and we are the complex access megacenter for our area (ie. the 'worst of the worst'). In my experience, you can always find something if you are facile with an ultrasound. Maybe once a month I'm asked to get an IV on one of our patients in pre-op, but it is incredibly rare. My favorite that is always available is a brachial vein on an arm already burned for dialysis access. Usually preserved because it is typically paired and nobody goes after it because it is deep and sitting next to the brachial artery, but it is extremely reliable. Not something I want everyone and their mother doing, but I would trust my current PGY2s to place one in a family member (happened a couple months ago) and expect my interns to acquire that level of skill with an ultrasound by December. If you are coming across this issue a lot, it is definitely something to look into.

dchz said:
This is a great time to bring this up:

Use the fistula.

Have you ever spoken to a vascular surgeon about why they won't let anyone use the fistula?? I got curious and chatted one up once: they want to extend the life of the fistula by minimizing people screwing it up. In the same conversation, he explicitly gave me (anes as a specialty) to use it:

"You guys place more and better IV than anyone and i don't think there is a group of people that's more qualified to take care of it. You prob can easily take care of it better than the dialysis nurses."

He also cited 0 concern about paradoxical emboli or infection risk. Therefore, I would not hesitate to place a 24 G and induce with any working fistula. (Or just attach a small needle in line and use it only to induce)


They can use it to exchange liters of blood but we have to poke them 30times to give them 30ccs of induction drugs??
Click to expand...

It is pretty rare that it is a vascular surgeon stopping people from using the fistula. Normally it is the nephrologist, patient or nursing. We know that there is nothing magical about the fistula. Take care of it and it will be fine, after all, they get abused all the freaking time in dialysis.
 
vector2 said:
LOL, an IO for an elective induction? Are you ****ting me? No elective case should be getting elective access where the complications theoretically include fracture, deep hematoma, fat emboli, and compartment syndrome. Even a CVL under U/S in experienced hands is preferable to an IO, but hopefully this can be avoided too.

If you can't find a vein with U/S in the AC, put a tourniquet on right at the armpit crease. Lay the patient's arm out like you were doing an axillary block. In 99.999% of patients you will see a juicy axillary vein right below the tourniquet, or if you go a bit distal and scan around there will be either a decent basilic, brachial, or cephalic vein. Use a 12cm 20g arrow, micropuncture, or argon kit and use seldinger. Takes 5 minutes.
Click to expand...
I like this. Will be my next skill to.learn! ICU only tho!
 
Arch Guillotti said:
Too much trouble sometimes. Just do an inhalation induction.
Click to expand...
Agreed. Last impossible IV situation for elective case I was in (sickler) we did sevo inhaled induction, few minutes of sevo and three different ppl trying an IV resulted in a usable 20 gauge within a few minutes.
 
Psai said:
The last few EJ's I tried were horrible. If you have someone who hates getting stuck because people keeping missing their veins, they're 10 times worse when you try to stick it in their neck. The last guy I tried it on was a IVDU for 10 years, terrible veins and he screamed bloody murder when I popped the plastic top off the iv. It was insanity.
Click to expand...

Sounds like the patient was really into theatrics
 
Even in the sickest vascular patient the best answer is likely an inhaled induction and search for an IV. You can probably even stick in an oral airway and let them breath on heavy sevo while you search for an IV if you work solo. If they’re a real bad vascularpath use the inhaled induction and find the next vein with ultrasound (also useful in Oscar Nominated IVDA)

I’ve only had one vascular patient give theatrics from the smell of the Sevo because she was a known difficult IV. I’ve personally fired myself from that patient
 
Can't believe y'all are willing to go to an inhalational induction that quickly (on sick pts no less) when there is a highly successful and almost painless (with local) technique available that even nurses use routinely to place PICCs.

Last week had a TAVR on an 80yo fat lady, mild dementia, EF 35%, pulm HTN, mechanical mitral. Gets sent to the cath lab with a 22g sticking out of her elbow. Realize it's not working after 50mcg of (subq) fent is administered through it. Bilateral arms including ACs have full surface area bruising from floor IV attempts. Legs are more swole than jay cutler. Abduct and tape her arm down, CRNA helps hold arm and whispers sweet nothings into her ear. Prep out, dump local, axillary IV and a-line are in within 10 min. Next.
 
I use ultrasound and the Arrow a-line catheter in these situations. Having the built-in wire to Seldinger the catheter over is crucial, and it's a kink resistant catheter too. Find whatever veins are there, get in at whatever angle, thread the wire, and boom, 20g PIV.

Just did it this morning on a HD patient who was an "impossible" stick.

Fast, easy, low risk. Try it.
 
Hawaiian Bruin said:
I use ultrasound and the Arrow a-line catheter in these situations. Having the built-in wire to Seldinger the catheter over is crucial, and it's a kink resistant catheter too. Find whatever veins are there, get in at whatever angle, thread the wire, and boom, 20g PIV.

Just did it this morning on a HD patient who was an "impossible" stick.

Fast, easy, low risk. Try it.
Click to expand...

Yep +1
 
Hawaiian Bruin said:
I use ultrasound and the Arrow a-line catheter in these situations. Having the built-in wire to Seldinger the catheter over is crucial, and it's a kink resistant catheter too. Find whatever veins are there, get in at whatever angle, thread the wire, and boom, 20g PIV.

Just did it this morning on a HD patient who was an "impossible" stick.

Fast, easy, low risk. Try it.
Click to expand...

This is what I do usually.

Recently had one for colonoscopy. If infiltrated mid procedure. Even used a 1 and 3/4 inch catheter and made sure I could draw blood back after placing. Patient had the saggy arm fat/tissue.

What's the solution to this? Just longer 12 cm catheter?
 
crash2500 said:
This is what I do usually.

Recently had one for colonoscopy. If infiltrated mid procedure. Even used a 1 and 3/4 inch catheter and made sure I could draw blood back after placing. Patient had the saggy arm fat/tissue.

What's the solution to this? Just longer 12 cm catheter?
Click to expand...


Yes. 12cm brachial Aline kit works very well for this purpose. You essentially get a midline catheter.
 
Arch Guillotti said:
Replacing a blown IV mid-procedure?
Click to expand...


No. I was replying to crash2500 who used a short catheter up front and had it infiltrate. For deep brachial veins I use the long catheter up front and never had one infiltrate. I suppose you could do it midprocedure although I never have.
 
narcotics999 said:
Side q: how many IOs have your guys done? Baby or adult?

I admit none.
Click to expand...
None placed here either. I will say I have only seen one used in an awake patient. As an ICU fellow, I got called to a rapid response for a lady in VT storm and her AICD was continuously shocking her while she was completely awake. Apparently she had terrible IV access and someone started an IO in her tibia right before I arrived. We attempted to use the IO and just the slightest amount of pressure to push drugs had the lady screaming louder than her shocks.

So after seeing that, I don't think it would ever be possible to start an IO for an elective case with difficult IV access. My go to will be US guided IV or CVL.
 
mac3gr1v said:
Apparently she had terrible IV access and someone started an IO in her tibia right before I arrived. We attempted to use the IO and just the slightest amount of pressure to push drugs had the lady screaming louder than her shocks.

So after seeing that, I don't think it would ever be possible to start an IO for an elective case with difficult IV access. My go to will be US guided IV or CVL.
Click to expand...

The distention of the bone marrow space hurts way more than the insertion of the needle, which seems to hurt surprisingly little in the few awake patients I have placed IO lines in. I give ~ 50 mg lidocaine slowly through the IO before any volume infusion and it seems to help a bit.
 
DrDrummer said:
The distention of the bone marrow space hurts way more than the insertion of the needle, which seems to hurt surprisingly little in the few awake patients I have placed IO lines in. I give ~ 50 mg lidocaine slowly through the IO before any volume infusion and it seems to help a bit.
Click to expand...

This is the protocol for placement in awake patients for most EMS systems. Were it me, I would never want anyone to infuse any appreciable volume without lidocaine first. In five years as a medic I’ve only needed to place two: one in a witnessed adult cardiac arrest (no veins at first glance and valued expediency in the situation), and in a shaken infant who was mottled and seizing uncontrollably. They work just fine if you know how to place and maintain them. For you folks, I can’t see any other use for them, given your experience and tools (meaning true life/death situations).

I’ve worked in an ED, as well, for most of my time as a medic, where the physicians encouraged some of us to learn to use an ultrasound to place peripheral IVs. I’ve probably done a thousand or more US guided at this point and would have to say that the modified rule from the house of god holds true: there’s no vein that can’t be reached with a 1.88 inch 18 gauge (or 14 gauge) angiocath and a good, strong arm. With enough practice it can be done very rapidly, as well.
 
Last edited:
85yo vasculopath coming to the burn OR yesterday. I take over the case from a colleague before the pt rolls and he tells me he was planning on sticking the EJ because the pt has no access and bilateral UE burns to just above the elbow.

No need to stick the EJ unnecessarily.

Tourniquet the axilla and slap the U/S on. Get a picture very similar to this one from emed. The basilic is the big vein on the right. The brachial veins (venae comitantes of the brachial artery) can be seen. These are typically smaller and the risk of arterial puncture is higher.

mYfAzfZ.png


My pt has an even bigger, fatter basilic vein. Nice. Prep out, dump a bunch of lido above the vein.

Go to kit is a 20g 15cm argon arterial line. Has a nice micropuncture style needle and soft tipped guidewire.

FhAx195.png


Done in 5-10 minutes. Surgeon preps the line into the field. The pt now has a reliable "midline" and he won't have to be stuck repeatedly during his hospital stay for IVs and he won't have to deal with potential complications from a PICC because IR and IV team here doesn't do midlines.
 
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