Hi everyone... I'm really looking for some input from board certified Critical Care physicians. I am a Surgery intern at two community hospitals, and our job at each hospital when "code blue" is called is to be there to make sure they have central access to deliver epinephrine. I've gotten pretty good at getting a femoral line within a few minutes. There is a major difference in administration of epinephrine between the two hospitals. At one hospital, they deliver epi through the currently working peripheral IV until we get there to establish a central line. At the other hospital, sometimes that will happen, but many times the nurses will put in an IO and push epi through that. When I get there I'm told "We don't need a central line... we have an IO." I understand the IO is an acceptable route to push pressors, but in the acute phase of ACLS is it preferable to vascular access? I just feel that pushing epi into a vein is preferable to the tibia during ACLS, but I was hoping someone could shed some light on what the textbooks or literature say.
Using an IO to push Epi during a code instead of a vascular route
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http://journals.lww.com/anesthesia-..._Improves_24_Hour_Survival_in_a_Swine.21.aspx
http://www.ncbi.nlm.nih.gov/pubmed/24402993
http://www.ncbi.nlm.nih.gov/pubmed/21871857
http://www.ncbi.nlm.nih.gov/pubmed/23248824
and so on and so on. You can find literature to support whichever side of the argument you want to be on.
My take...
The issue isn't speed of delivery. At minute 1 with both (minute 0 being the push of epi), you'll have a greater serum concentration with an IV push than an IO push.
But in the code, minute 0 is the start of the code. You can have an IO placed by minute 1 and the epi pushed. The femoral line doesn't get in until minute 5 or 8 or 10, etc...
By that point the difference in the serum concentration isn't that much because the IO dose has reached a higher concentration, plus you're probably on dose #2 or #3.
Even when I'm at the bedside for the start of a code, I get an IO placed right away and start pushing the code drugs through that. If we start to show signs that we'll get ROSC, then I'll put in the crash femoral line for pressor drips. Or if the person is profoundly hypovolemic, we'll start things off with bilateral IOs, then drugs and fluids can be running in while I'm getting the femoral or subclavian (depending on whether CPR is actively ongoing).
http://www.ncbi.nlm.nih.gov/pubmed/24402993
http://www.ncbi.nlm.nih.gov/pubmed/21871857
http://www.ncbi.nlm.nih.gov/pubmed/23248824
and so on and so on. You can find literature to support whichever side of the argument you want to be on.
My take...
The issue isn't speed of delivery. At minute 1 with both (minute 0 being the push of epi), you'll have a greater serum concentration with an IV push than an IO push.
But in the code, minute 0 is the start of the code. You can have an IO placed by minute 1 and the epi pushed. The femoral line doesn't get in until minute 5 or 8 or 10, etc...
By that point the difference in the serum concentration isn't that much because the IO dose has reached a higher concentration, plus you're probably on dose #2 or #3.
Even when I'm at the bedside for the start of a code, I get an IO placed right away and start pushing the code drugs through that. If we start to show signs that we'll get ROSC, then I'll put in the crash femoral line for pressor drips. Or if the person is profoundly hypovolemic, we'll start things off with bilateral IOs, then drugs and fluids can be running in while I'm getting the femoral or subclavian (depending on whether CPR is actively ongoing).
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An IO is better than nothing, but the moment ROSC is obtained central access should obtained and once that happens I remove IOs, they look like they hurt like hell.
Thanks Doctor Bob... I have done some preliminary searches which seemed to support either which is why I posted on this forum and I do appreciate the links.
But I do want to clarify something. At this hospital the nurses can place IOs and on many occasions will stop using a perfectly good working peripheral IV to place an IO for Epi. So if you had a good peripheral IV to push Epi through, should you switch to using the IO during a code? It would seem to me like a good peripheral would be better to get Epi to the heart than infusing through and IO.
But I do want to clarify something. At this hospital the nurses can place IOs and on many occasions will stop using a perfectly good working peripheral IV to place an IO for Epi. So if you had a good peripheral IV to push Epi through, should you switch to using the IO during a code? It would seem to me like a good peripheral would be better to get Epi to the heart than infusing through and IO.
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Don't forget that you can put epi in the ET tube. It isn't ideal but when you're in a bind....
D
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Route doesn't matter because epi probably does nothing.
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I would still place the IO. Only because those peripheral IV lines blow real fast when the overeager floor nurse tries to pressure-push the amp of epi. If the line flushes easily, and the nurse is experienced and pushes it at an appropriate rate, sure, it's a good option until something better comes along. But 9 times out of 10 the adrenaline surge the staff experiences during a code translates into a lot of blown peripherals.
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Route does matter when pushing Epi regardless of wether it may make a big difference. If you're going to push and you blow a peripheral vein and all that Epi goes into the sub-q, you might a problem on your hands. All things being equal try not to push through a peripheral line - though we all do when we think the clinical situation warrants.
I like the IO. Get it in and then forget that part of the equation work on the rest of the patient. I remember the days of the surgical intern digging and digging in some crumping patient's inguinal region for a long long time and I like the quickness of the IO. I get them out quick if the patient lives.
