interosseous access (IO)

leslie :-D · Jul 19, 2007

is giving meds through an ett an acceptable route?

is it commonly used?

i just can't see putting meds in the lungs!

the pt can't aspirate?

leslie

Christie RN2006 · Jul 19, 2007

is giving meds through an ett an acceptable route?
is it commonly used?
i just can't see putting meds in the lungs!
the pt can't aspirate?
leslie

You have to be ACLS certified to push meds in an emergency situation and IV/IO is the AHA preferred route, but via the ETT is also acceptable. Things have to be pretty bad before we will give meds via the ETT. There are only certain meds that can be given via the ETT... I believe it is "LANE" please correct me if I'm wrong...

L=lidocane

A=atropine

N=narcan

E=epinephrine

The problem I have with doing that is that in order to get the effect needed from the meds you have to push a lot of fluid into the lungs and normally fluid in the lungs is one of the problems to begin with! Yes, the pt aspirates, that is the point.... I have only ever done it this one time and I hope I won't have to do it again for a while. The pharmacist was like "I have never seen that done before"... this pharmacist has been around for a while, so that shows you how rare it is.

Christie RN2006 · Jul 19, 2007

Hi. I am in my final year of nursing school and we learnt about IO access and how to insert them last week.
You are right in that sternum IO access is usually only used in adults, it was designed to be used by the army because it is much easier than going into femur or other bone (a ring of small needles holds the device in place while the main needle shoots through into the marrow).
I was surprised at how easy it was to insert, even manually! Didnt require too much strength to push it through the bone and the needle was quite blunt. Apparently is you dont have a proper one it is possible to do it with a large gauged needle in an emergency situation.
Basically any meds can be passed into it, followed by a flush and enter circulation really quickly. IO access can be left in for a few days, there is a risk for infection though and...ITS EXPENSIVE! Each needle is around NZ$300!

I have always heard that you are not supposed to leave them in any longer than 24 hours.

Kidrn911 · Jul 19, 2007

ACLS now covers IO (interosseous) access in code situations... I was just wondering how many of your facilities have started using IO for codes where you can't get IV access? If you have used IO, what do you think of it and what was the outcome? Would you recommend it for hospital settings or just prehospital?
I was involved in a code situation last night where we lost the IV and no one was able to start one and the doc was unable to place a line. We ended up having to give meds via the ETT! I honestly doubt IO access would have saved the patient in that situation, but it would have been definitely useful! I could see it coming handy in some of our code situations.

It is rare we can't get a line, but we don't hesitate using the IO either. Irony is it is often our paramedics that we not only reach for the IO but teach the residents how to put it in.

Christie RN2006 · Jul 19, 2007

It is rare we can't get a line, but we don't hesitate using the IO either. Irony is it is often our paramedics that we not only reach for the IO but teach the residents how to put it in.

From using IO, what do you think about it? I would like to see IO access be used at my hospital during code situations when we are unable to get IV access. I am just curious what everyone that uses IO thinks about it, whether it is beneficial or not.

Medic/Nurse, BSN, RN · Jul 19, 2007

There is "traditional" IO access with the IO needle and it is placed in the proximal tibial tuberosity - this is primarily done in pedi patients.

Technique is important - site prep is essential. Gather all supplies and have help - I do not aspirate - but flush and ensure that there is no infiltration and free flow is possible. I have placed several this way and have never had a problem.

Lately, there have been proprietary devices for use in adults and peds. These include Pyng Sternal EZ IO, that was military developed and is fairly easy to place - offers rapid set up. IF a person is large in the chest/sternal area it may be difficult because depth is set.

There are also a BIG type device, a spring loaded injector gun for placement in the tibia, proximal humerus and the radius site is being investigated. Easier to use, offer additional sites and less $$$.

All methods avoid congenital conditions of the bones, fractured areas and severe wounds/burns to the area being used.

Hope this helps.

Practice SAFE!

The new methods are nice, but I'm old school and as such, I'm fairly comfortable with any method necessary. :)

TiffyRN, BSN, PhD · Jul 19, 2007

Someone showed me an IO device once and once it's in there is like a luer tip you screw IV tubing into and just treat it like an IV device. I've never seen it done or one in place so that 's the limit of my knowledge. Bone Marrow being highly vascular gets to general circulation extremely fast.

As for ETT meds; the med is injected straight down the ETT followed by a prescribed amount of NS (different for adults then infants which I deal with) and then the patient bagged real well after to distribute the med through the lungs to the pulmonary capillaries by the alveoli (I think). That's why it works, getting the med to the capillaries therefore the general circulation. Not ideal, but it works in a pinch.

It's used fairly often in resuscitation of infants when IV access either can't be established or hasn't yet been established. In fact, seems like I remember from my NRP that in a delivery room infant code if one needed meds given one would give it per ETT first before even attempting to get IV access (which would be emergency umbilical line).

Rach101 · Jul 19, 2007

check out http://www.emedicine.com/ped/topic2557.htm

they can be left in for 72- 96 hours but risk of infection increases.

TazziRN, RN · Jul 19, 2007

You have to be ACLS certified to push meds in an emergency situation and IV/IO is the AHA preferred route, but via the ETT is also acceptable. Things have to be pretty bad before we will give meds via the ETT. There are only certain meds that can be given via the ETT... I believe it is "LANE" please correct me if I'm wrong...
L=lidocane
A=atropine
N=narcan
E=epinephrine
The problem I have with doing that is that in order to get the effect needed from the meds you have to push a lot of fluid into the lungs and normally fluid in the lungs is one of the problems to begin with! Yes, the pt aspirates, that is the point.... I have only ever done it this one time and I hope I won't have to do it again for a while. The pharmacist was like "I have never seen that done before"... this pharmacist has been around for a while, so that shows you how rare it is.

It's not that rare, not in the ER. I've seen it done a lot and I've done it a lot. It might not be as common now because of IO, but years ago (and not that many years ago!!) IOs were only for small children. Like the IO, it is done only until a line is placed.

After each med via ET, you also give 10 ml NS, then ventilate hard to push it through.

TazziRN, RN · Jul 19, 2007

It is rare we can't get a line, but we don't hesitate using the IO either. Irony is it is often our paramedics that we not only reach for the IO but teach the residents how to put it in.

A medic talked me through my first one! She brought the pt in and was unable to get a line. We couldn't either, and when the doc ordered the IO all three nurses looked at each other with a deer in the headlights look....none of us had done it outside of ACLS and PALS recerts. The medic, whom I've known for many years, just stepped up beside me and quietly started telling me what to do. Nailed it.

Vanfnp · Jul 19, 2007

The latest ACLS guidelines do advocate greater use of IO devices. After renewing my certification, our ER had opportunity to use one in an adult code situation. We have the "gun" type device that works very similar to a cordless screwdriver. We used the tibial plateau and the device worker very well-you need to immediately flush w/ 10 cc of saline to get the "plug" out of the way. We also found a pump works best for fluids; you need that bit of pressure.

Altra, BSN, RN · Jul 19, 2007

It is rare we can't get a line, but we don't hesitate using the IO either. Irony is it is often our paramedics that we not only reach for the IO but teach the residents how to put it in.

Same here, in peds situations.

I participated in one peds code where we gave meds both via IO and ETT until we got a central line.

I do find IOs creepy. Effective, if properly placed, but still creepy.