IO + Lab work

[applesxoranges]

So an ER physician said you could get lab work off of an IO when we were discussion how I sent a patient to ICU recently with just an IO because ED physician failed to place a central line x 3, no IV access, and no access for even a PICC line. The PICC line nurse even commented that she was under the impression he was supposed to have a port placed due to the difficulty of obtaining access.

I was under the impression that you would be just aspirating bone marrow if you drew off of a IO. Could you actually run any regular lab work like a CBC or chem off it?

[bgxyrnf, MSN, RN]

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.

[TheSquire, DNP, APRN, NP]

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.

Dunno about your department, but in mine there's a sizable minority of RNs trained in U/S PIV placement (small enough that they do enough of them to keep their hands in, but large enough that you're probably going to have one on a given shift). That said, this skill isn't something our scheduler takes into account, so some shifts there's no one who does U/S PIVs, and you're SOL.

[applesxoranges, BSN, RN]

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.

We had the PICC nurse there and they will also do ultrasound IVs first if they see adequate veins. In this case, there was nothing. The PICC nurse was familiar with the patient and recalled that he was supposed to have a port placed because they were not getting any access with him.

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).

There was literally nothing there. The physician was unable to obtain a central line via ultrasound or old methods (he an experienced, competent ED physician that has worked in trauma centers). There was nothing for an EJ. On one side of his neck the skin was irritated from a previous central line. The IJ wasn't exactly the best.

His lower half was malformed.

[applesxoranges, BSN, RN]

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.

They are "in house" at our facility 9-6ish week days and on call on the weekends 9-5. They also do ultrasound for IVs. I guess they also change dressings on the PICCs.

[offlabel]

Definitive volume resuscitation that is life saving apart from large bore peripheral access is accomplished with "sewer pipe" type central access facilitated by u/s. Goofing around with I/O or u/s for peripheral access to "buy time with volume" until definitive central access is achieved is IMHO, kidding yourself. An entire unit of packed cells can go in centrally in the time someone goofs around with abandoning PIV access and going to I/O access.

An u/s guided IJ is a 3 minute deal, and if it is too much longer than that, someone needs to come in who is able to do it.

[offlabel]

Definitive volume resuscitation that is life saving apart from large bore peripheral access is accomplished with "sewer pipe" type central access facilitated by u/s. Goofing around with I/O or u/s for peripheral access to "buy time with volume" until definitive central access is achieved is IMHO, kidding yourself. An entire unit of packed cells can go in centrally in the time someone goofs around with abandoning PIV access and going to I/O access. An I/O is not for rapid infusions so wasting time with one in that situation when u/s is available is...well...wasting time.

An u/s guided IJ is a 3 minute deal, and if it is too much longer than that, someone needs to come in who is able to do it.

[bgxyrnf, MSN, RN]

An u/s guided IJ is a 3 minute deal, and if it is too much longer than that, someone needs to come in who is able to do it.

In general, I agree with your post. It is worth noting, however, that some of the smaller community or rural hospitals do not have multiple providers around and most of the older docs have minimal to no proficiency with ultrasound... and may not have access to an ultrasound at all.

[offlabel]

In general, I agree with your post. It is worth noting, however, that some of the smaller community or rural hospitals do not have multiple providers around and most of the older docs have minimal to no proficiency with ultrasound... and may not have access to an ultrasound at all.

I'll take your word for it, but when you can buy a simple good, used u/s machine on eBay, there is no excuse at all. U/S workshops for cme's are every where. Not being able to do an u\s guided central line is third world medicine.