IO + Lab work

Some labs can be done after the initial aspiration, white count and platelet count will be way off with I/O. H&H and RBC is about the same as IV.

There are a few others that can be run too, don't remember off hand (glucose I am pretty sure of).

Edit: Google search has several articles that have information that seems to agree with each other.

All say I/O blood draws will have a white count that is higher, CO2 and platelets will be lower compared to IV.

I/O Glucose, blood urea nitrogen, creatinine, chloride, total protein, and albumin are about equal to IV.

Potassium seems to have mixed results.

To whatever degree you can aspirate blood from an IO line, it can be used for basic labs.

I have a big issue with sending a patient to the ICU with no venous access, though. By local policy, IOs are good for no more than 24 hours - unless it's a field start, then it's remove as soon as possible. Additionally, the flow is so restricted through an IO that you can't fluid resuscitate. And just because you *can* run medications through them, it's suboptimal.

I don't see how it's acceptable to say, "we can't get venous access" in the ED. If nothing else, the docs can do a venous cutdown if every other option has been tried unsuccessfully.

In seven years of ED nursing, I've yet to encounter patient on whom some form of IV access couldn't be established, be it EJ, IJ, deep brachial, or a fem line - or a saphenous cutdown (only once).

With the advent of routine ultrasound use, I'm astounded that I/O lines are even considered anymore. That is 3rd world medicine if it's not placed in desperation in the field.

I am not astounded that IO has one again emerged as another alternative to gain vascular access. As with any IV access it definitely has pros and cons. The reality is that timely access cannot always easily be achieved and IO is very fast and treatment can be initiated while you are still trying to get another and hopefully better access in place. Just because one is trained in the use of Ultrasound does not mean that access is easy and thus a sure thing! I have also found that the mix of trained clinicians on any one shift can vary greatly. One day we may have practitioners that are great at it and others that will do anything not to have place a line or try multiple times without success.

IO is just another tool in the tool box and has its place. It can get a patient over the hump until something else can be placed. I take more out than I have ever placed and that is after I started a PIV or PICC. I can tell you that the patients were very happy that they were treated so quickly. I see them placed mostly during the night shift in the ED and out in the field.

I'm all for US guided PIV, and I place a ton of them, but I cant say they totally negate the utility of IO access in emergent situations. When their pressure is in the toilet, and they are clamped down, the time to spend much time fiddling with US has passed generally. If i dont see something quickly with US, and they dont have a good EJ, I'm probably going to ask someone to drill in an IO and start some fluids and/or blood while I keep looking. Fill the tank a little via the IO, then upgrade vascular access.

Just don't draw a CBC off the IO; remember, it's in the marrow and thus whatever you draw is going to have immature cells in it. If you do, lab's going to call you back and tell you that the patient has every kind of blood cancer...

I have a big issue with sending a patient to the ICU with no venous access, though. By local policy, IOs are good for no more than 24 hours - unless it's a field start, then it's remove as soon as possible. Additionally, the flow is so restricted through an IO that you can't fluid resuscitate. And just because you *can* run medications through them, it's suboptimal.

Other than the time requirements, everything else in this paragraph is refuted in the literature, especially for humeral IOs but even for proximal tibial IOs as well. I can get more volume in faster than with most IVs, and time to central circulation is

I don't see how it's acceptable to say, "we can't get venous access" in the ED. If nothing else, the docs can do a venous cutdown if every other option has been tried unsuccessfully.

In seven years of ED nursing, I've yet to encounter patient on whom some form of IV access couldn't be established, be it EJ, IJ, deep brachial, or a fem line - or a saphenous cutdown (only once).

Yes, you can get access...after 5-10 minutes of trying, whereas I can drill an IO faster than it took me to type this sentence. When you need access now, the IO is the way to go.

I highly suggest you go to a cadaver lab run by one of the IO vendors. Its one thing to read about how IOs work, but actually practicing and also seeing it makes a world of difference.

Other than the time requirements, everything else in this paragraph is refuted in the literature, especially for humeral IOs but even for proximal tibial IOs as well. I can get more volume in faster than with most IVs, and time to central circulation is

Yes, you can get access...after 5-10 minutes of trying, whereas I can drill an IO faster than it took me to type this sentence. When you need access now, the IO is the way to go.

I highly suggest you go to a cadaver lab run by one of the IO vendors. Its one thing to read about how IOs work, but actually practicing and also seeing it makes a world of difference.

Agreed, if you have no access and need it immediately, and a PIV site isn't readily available, then an IO is absolutely the way to go. In six years of ED nursing, I can only recall a handful of times that I've had to resort to an IO line and each time, it was a bridge (as you say) to definitive access.

In each of those cases I have found it to take much more pressure to infuse through the IO than through a solid 20-ga line, let alone a 16 ga or, much better yet, an emergency Cordis line.

I'd be quite interested in the literature that you've seen that refutes restricted flow through an IO line. I'm only drawing on limited (~5) personal experiences trying to run the rapid infuser through an IO line or hand pumping blood or pushing meds. I'm also interested in the studies that you've read which indicate that medications are bioavailable at the same rate through an IO as they are though a well-placed venous catheter. I've been told by a surgeon during a trauma case that this is not the case, and the anatomy would seem to argue against it but I'd certainly defer to well-documented literature.

In our institution, the patients do not leave the ED until they have adequate venous access. I suppose I've fallen into the common trap of extrapolating my experience to apply to all institutions. Still, though, it's hard for me to imagine that a patient who's been in the ED for any length of time wouldn't have a line placed in addition to the emergent IO.

And please do note that I didn't say anything about opting for a 10-minute attempt at venous access in favor of a 1-minute IO for an emergent situation but rather that I see no reason to justify sending a patient out of the ED with *only* an IO as the access to venous circulation.

I'd be quite interested in the literature that you've seen that refutes restricted flow through an IO line. I'm only drawing on limited (~5) personal experiences trying to run the rapid infuser through an IO line or hand pumping blood or pushing meds.

God created the pressure infuser for a reason. That being said, yes, I can probably run fluids faster with a 16g and a pressure infuser than an IO...but if I need an IO, it's on a patient that doesn't have veins for a 16g, else I'd be using that.

I'm also interested in the studies that you've read which indicate that medications are bioavailable at the same rate through an IO as they are though a well-placed venous catheter. I've been told by a surgeon during a trauma case that this is not the case, and the anatomy would seem to argue against it but I'd certainly defer to well-documented literature.

In our institution, the patients do not leave the ED until they have adequate venous access. I suppose I've fallen into the common trap of extrapolating my experience to apply to all institutions. Still, though, it's hard for me to imagine that a patient who's been in the ED for any length of time wouldn't have a line placed in addition to the emergent IO.

To be honest, I'm putzing around on allnurses as an occasional distraction for doing work on DNP classes, and already have 20 tabs open on research for other stuff, so I'll just foist you onto Teleflex's website for clinical information on IOs.

Now, would I try to get other venous access, especially if I need a line for propofol for sedation, another for antibiotics, and would like to run my pressor through the IO (because of near-central line quality)? Yes. Would I want a line I can draw a CBC off of? Yes. But if fluid resuscitation isn't improving the quality of the patients veins (and we've all had patients with veins that bad), none of my coworkers trained in starting US-guided PIVs are working that shift, and it's a simple case that doesn't require any dedicated lines (or they're still unresponsive and I can drill a second IO without feeling bad about it) I have no compunctions about sending a patient up with only IO access and making it a floor problem. The IO's good for 24 hours, and unless the floor's stalling with accepting patients I've used at most three of those hours.

God created the pressure infuser for a reason. That being said, yes, I can probably run fluids faster with a 16g and a pressure infuser than an IO...but if I need an IO, it's on a patient that doesn't have veins for a 16g, else I'd be using that.

To be honest, I'm putzing around on allnurses as an occasional distraction for doing work on DNP classes, and already have 20 tabs open on research for other stuff, so I'll just foist you onto Teleflex's website for clinical information on IOs.

Now, would I try to get other venous access, especially if I need a line for propofol for sedation, another for antibiotics, and would like to run my pressor through the IO (because of near-central line quality)? Yes. Would I want a line I can draw a CBC off of? Yes. But if fluid resuscitation isn't improving the quality of the patients veins (and we've all had patients with veins that bad), none of my coworkers trained in starting US-guided PIVs are working that shift, and it's a simple case that doesn't require any dedicated lines (or they're still unresponsive and I can drill a second IO without feeling bad about it) I have no compunctions about sending a patient up with only IO access and making it a floor problem. The IO's good for 24 hours, and unless the floor's stalling with accepting patients I've used at most three of those hours.

As I said, I've never seen it appropriate to have a patient in the ED for any length of time and not obtain and IV of some sort and I'd certainly not be comfortable "making it a floor problem."

You've got your practice and I've got mine. Nothing you've said gives me pause to reconsider my views.

All the best to you.

To whatever degree you can aspirate blood from an IO line, it can be used for basic labs.

I have a big issue with sending a patient to the ICU with no venous access, though. By local policy, IOs are good for no more than 24 hours - unless it's a field start, then it's remove as soon as possible. Additionally, the flow is so restricted through an IO that you can't fluid resuscitate. And just because you *can* run medications through them, it's suboptimal.

I don't see how it's acceptable to say, "we can't get venous access" in the ED. If nothing else, the docs can do a venous cutdown if every other option has been tried unsuccessfully.

In seven years of ED nursing, I've yet to encounter patient on whom some form of IV access couldn't be established, be it EJ, IJ, deep brachial, or a fem line - or a saphenous cutdown (only once).

It takes a fair amount of time to start an U/S guided PIV and it isn't 100% successful. Also remember that the PICC nurse couldn't do a PICC line in the ER (which I've never seen them in any ER I've worked in) so the likelihood of starting an ultrasound line is slim to none. That PICC RN should also be trained in U/S PIV placement.

It takes a fair amount of time to start an U/S guided PIV and it isn't 100% successful. Also remember that the PICC nurse couldn't do a PICC line in the ER (which I've never seen them in any ER I've worked in) so the likelihood of starting an ultrasound line is slim to none. That PICC RN should also be trained in U/S PIV placement.

As I said, I'm not talking about the initial resuscitation. I'm talking about prior to transporting the patient out of the ED. After the first 30 minutes or so, there is no reason not to establish IV access, either peripherally or centrally.