what is the consensus regarding IV size and placement? go big within reason, 18g in the AC, or small and distal 20g below the AC?
what is the flow difference between these two? time for a liter to flow through a 16, vs. 18 vs. a 20? i know some CT contrast can't go into a 20 (head CT? do to the slower speed?)
during a recent ACLS class the instructor noted the increased speed and accuracy of dropping (drilling) in an IO vs. an IV and alluded to trauma situations going to the IO route over IV. how long can an IO remain in place? and what gauge are they? big i assume.
With all due respect I believe you are clouding the issue. IO's are never intended to be used for "massive fluid volume resuscitations" and certainly not with a rapid infuser. Using an incorrect application to support your apparent dislike for the IO route is at best disingenuous and at worse misleading. Nobody is putting forth that the IO route is perfect but it is, however, an easy, effective and rapid manner to gain access in a patient who needs IMMEDIATE intervention until such time that a definitive route, be it peripheral or central, can be obtained.
Furthermore, nobody has made any claims that IO's have any influence over the morbidity/mortality of trauma or cardiovascular collapse patients. As kmoonshine pointed out the patient's who get IOs are the ones who are statistically in the "crapper" if you pardon my expression. Do you honestly think they had a better chance with NO ACCESS at all. These are the patients that you can't get anything in; not peripherally not centrally. So the fact that they showed no improvement in M&M is statistically insignificant. But at least every attempt was made.
In addition, while I have a great deal of respect for Dr. Bledsoe, especially regarding his views on HEMS, to cite him (from a forum no less) soley as support for your position is extremely weak. He is expressing an opinion only and with no statistics posted to support his views. Not only that but the opinion is being taken out of context and I encourage everyone to read the entire post, especially the comments following his that do cite studies supporting the use of IOs in EMERGENT situations. And that is from where I think the disagreement is stemming. We aren't talking IOs as appropriate to use in every situation which the "anti IO" faction seems to be misconstruing. IO acess is an appropriate and effective tool for use in a patient who needs immediate intervention and where rapid peripheral access has been unsuccessful. Yes a CVC of some sort is preferable for further care and no an IO is not a replacement for one.
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
With all due respect I believe you are clouding the issue. IO's are never intended to be used for "massive fluid volume resuscitations" and certainly not with a rapid infuser. Using an incorrect application to support your apparent dislike for the IO route is at best disingenuous and at worse misleading. Nobody is putting forth that the IO route is perfect but it is, however, an easy, effective and rapid manner to gain access in a patient who needs IMMEDIATE intervention until such time that a definitive route, be it peripheral or central, can be obtained.
Furthermore, nobody has made any claims that IO's have any influence over the morbidity/mortality of trauma or cardiovascular collapse patients. As kmoonshine pointed out the patient's who get IOs are the ones who are statistically in the "crapper" if you pardon my expression. Do you honestly think they had a better chance with NO ACCESS at all. These are the patients that you can't get anything in; not peripherally not centrally. So the fact that they showed no improvement in M&M is statistically insignificant. But at least every attempt was made.
In addition, while I have a great deal of respect for Dr. Bledsoe, especially regarding his views on HEMS, to cite him (from a forum no less) soley as support for your position is extremely weak. He is expressing an opinion only and with no statistics posted to support his views. Not only that but the opinion is being taken out of context and I encourage everyone to read the entire post, especially the comments following his that do cite studies supporting the use of IOs in EMERGENT situations. And that is from where I think the disagreement is stemming. We aren't talking IOs as appropriate to use in every situation which the "anti IO" faction seems to be misconstruing. IO acess is an appropriate and effective tool for use in a patient who needs immediate intervention and where rapid peripheral access has been unsuccessful. Yes a CVC of some sort is preferable for further care and no an IO is not a replacement for one.
All I'm alluding to as far as the Bledsoe reference is that he notes that there has been no evidence supporting improved outcomes with I/O use... It's like EMS backboards, we're just using them (I/O's) without science proving them to make a difference.
We don't need evidence to prove that they don't help - we need evidence to show they do. You don't attempt to prove the negative, when the positive aspects haven't been proved yet.
That's all I'm saying is that it's something that's being marketed to us healthcare providers as the "golden" option. I'm just advocating for public research to be done before something is touted as the "standard of care" in "x-y-z" scenario. (Please refer to Steroid use in Spinal cord injuries for another "sacred cow").
I work w/a huge senior population in an extremely busy ER. We put a line where ever we can get it - hand, ac, any place in the arm. We don't have time to hunt around. I've never seen a femoral line, but have assisted docs with femoral sticks in cases where there are no veins left (renal pts, chemo pts, junkies). They then get a picc or ij line. The 20gauge is the favorite. I've used 18's on those w/good veins. I used a 24 on a thumb once, but anything less than a 20 is kind of a waste.
I've never seen a IO used (yet), just learned about them in ACLS. The instructor said he could place it faster than an IV line. I guess if you are in the field and the pt is bleeding out, it really doesn't matter what if it's iv or io, just that it's there. This guy worked in Newark, NJ and it's really rough up there. Newark Beth Israel is an excellent hospital where they see the worst of the worst and I don't think they care if the line is iv or io, just that it's done.
All I'm alluding to as far as the Bledsoe reference is that he notes that there has been no evidence supporting improved outcomes with I/O use... It's like EMS backboards, we're just using them (I/O's) without science proving them to make a difference.
We don't need evidence to prove that they don't help - we need evidence to show they do. You don't attempt to prove the negative, when the positive aspects haven't been proved yet.
That's all I'm saying is that it's something that's being marketed to us healthcare providers as the "golden" option. I'm just advocating for public research to be done before something is touted as the "standard of care" in "x-y-z" scenario. (Please refer to Steroid use in Spinal cord injuries for another "sacred cow").
Thanks for your comments - I love the dialogue.
So I might better understand your viewpoint what exactly is your issue with the use of IO's? Have you had a negative experience with their use or with someone from VidaCare? I have a great deal of experience with all types of access devices from IO to central lines and I can tell you the abitlity to place an IO indeed has made the difference between life and death in some of my patients. I'm also not sure what you mean by "public research". I googled the term intraosseous and found all sorts of independent studies regarding the efficacy of their use in emergent situations. Granted I did not find one that spoke specifically to the subject of morbidity/mortality rates but common sense would tell you that any access is better than no access. I would hazard a guess that the M/M rates would be no different than those of patients in similar situations where a PIV was able to be obtained in an equal amount of time. You seem to be implying that they don't work when there is plenty of research to prove that they do. The science is there, yet you seem to be turning a blind eye to it which I don't understand. So please enlighten me as to your experience with IO's so I might get a better understanding of your position.
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
So I might better understand your viewpoint what exactly is your issue with the use of IO's? Have you had a negative experience with their use or with someone from VidaCare? I have a great deal of experience with all types of access devices from IO to central lines and I can tell you the abitlity to place an IO indeed has made the difference between life and death in some of my patients. I'm also not sure what you mean by "public research". I googled the term intraosseous and found all sorts of independent studies regarding the efficacy of their use in emergent situations. Granted I did not find one that spoke specifically to the subject of morbidity/mortality rates but common sense would tell you that any access is better than no access. I would hazard a guess that the M/M rates would be no different than those of patients in similar situations where a PIV was able to be obtained in an equal amount of time. You seem to be implying that they don't work when there is plenty of research to prove that they do. The science is there, yet you seem to be turning a blind eye to it which I don't understand. So please enlighten me as to your experience with IO's so I might get a better understanding of your position.
I'm aware that research has proven that they are (1) quick to insert (2) simple to insert (3) easy to use and (4) equitable as an IV.....
...however....
There isn't research to support the conclusion that it improves outcomes (dead is dead no matter how you slice it).
I'll grant that an I/O may be useful in certain situations to enable fluids or meds, however, does that same I/O increase overall outcomes? (IE: survival to hospital discharge?).... or even in some combat situations where you have penetrating/blast trauma and someone (like a combat medic) is right there to start it immediately..... (but then now we're starting to talk about the current philosopy of "permissive hypotension" in which IV/IO access is not the priority step but rather hemorrhage control)....
If it doesn't suppport this, then why are we supporting more healthcare associated costs and expensive devices and inservice/training times?
I agree about the ease of use and the simplicity, I just don't see it making a difference in patient survival - or at least it hasn't been proven to me - so I ask "why" must we take on another task if it doesn't change the outomes (IE: dead is dead....)
Overall, I've had no bad experiences with them at all, but in my observations I have seen people think they were "life savers"; when in actuality and technically speaking, no one has proved that they "save lives".....
So then...what is your suggestion for what to do when you can't get a PIV or central line and your patient needs resuscitation drugs or fluid (not a candidate for permissive hypotension...gotcha;)). Should we just throw our hands up in the air and say "sorry, dude, you're toast" because we don't want to spend the few extra dollars on a proven alternative. I'm not talking about putting an IO in the cyanotic "bum-sicle" with an unknown downtime who comes in clearly dead and irretrievable or the trauma patient with brain matter coming out of his nose. I'm talking about the three year old septic kid who is completely shut down and needs fluids or pressors NOW to prevent a most certain arrest event or ramp that up to a 20 year old sudden arrest from an unknown arrhythmia who had immediate defibrillation and is now with a pulse but a BP too low to perfuse an otherwise healthy brain. I absolutely don't believe you should throw an IO in everyone but there are more than just a few situations where having some sort of access will absolutely make a difference in outcome. Not only that but I do have the experience where having an IO did make a difference because we were able to give epi in an arrest situation within seconds of the onset of the event. The outcome was the patient went home a few days later and is living a normal life. And this is not an isolated incident for myself or for my teammates. Again with all due respect,until you have had a personal experience where having an IO did or did not, indeed, save a life you really aren't qualified to speak authoritatively on the subject. Obviously you most certainly have the right to voice your opinions but by your own admission your observations are really only disagreements with the statements of others who feel that having an IO in place made a difference. Your argument that the long term outcome hasn't been proven does not stand up to reason. If you follow that track then we should probably not put in PIV's at all because there are no studies proving that they improve outcomes anymore than IO's or for that matter why waste money on expensive CVL's. In fact, why do we bother coding anyone in the first place if we can't guarantee that after we expend all those resources the patient will live. After all, "dead is dead". The problem is you want to make medicine concrete and it simply isn't. It's fluid and constantly changing.There are no guarantees. To require that will only frustrate you and make you incapable of adapting. This has been a completely enjoyable dialogue. Thank you for keeping it civil.
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
good reply - Touche'
In your scenario, I would place an IO, but I would realize that we may just be "going through the motions" so to speak; kind of like chest compressions in the field during. CPR - you're just "going through the motions.
But just to clarify, all of the foregone discussion about IO's is not based on mere observation - it's just I've been looking for the "proof in the pudding" and I don't see it....
Maybe someone needs to do a study; but it would hard to do it "double blinded" as it would be fairly obvious which patients had IO's vs IV's.... (which would incur observer bias).
Unfortunately I think all we can reasonably do is retrospective chart reviews....
...and, as you mentioned the hypotensive pediatric pt, let me be clear I am (I should have said this before) only talking about adult patients in regards to IO's and end point M & M (IE; discharge from hospital with a quality of life)...
I would again like to point something out: what do we use IV's and I/O's for? To give medications and administer fluids. And does an I/O deliver medications like an IV (as far as onset, distribution)? Pretty darn close.
So, does research show that ACLS meds and fluid resuscitation improve outcomes in the dying patient? For the most part, yes. And can these ACLS meds be given either IV or I/O? Yup.
Since an IV is comparable to I/O in terms of medication administration, and these meds can save lives, we can argue that YES, I/O's have the potential to improve outcomes. However, those patients who receive I/O's are far sicker to begin with and have a higher mortality rate regardless.
In terms of cost, an I/O is pennies compared to the cost of cracking a code cart. Training-wise, demonstrating the basic placement of an adult I/O using an I/O drill takes mere minutes. A lot less time than the "customer service" class (an hour long) that I had to take. And customer service doesnt save lives...
what is the consensus regarding IV size and placement? go big within reason, 18g in the AC, or small and distal 20g below the AC?
what is the flow difference between these two? time for a liter to flow through a 16, vs. 18 vs. a 20? i know some CT contrast can't go into a 20 (head CT? do to the slower speed?)
during a recent ACLS class the instructor noted the increased speed and accuracy of dropping (drilling) in an IO vs. an IV and alluded to trauma situations going to the IO route over IV. how long can an IO remain in place? and what gauge are they? big i assume.
dan
IO is the way ACLS is now stating should go if IV access is delayed or unavailable for meds, rather than the 'ol ET tube route for meds.
I would imagine if successful, IO would be removed for placement of an IV (TLC, EJ...etc) once patient is stable. IO's are humongous.... larger than a 14 gauge IV
I can cite Bryan Bledsoe that "there is no emprical evidence" to support their usage.
I would challenge anyone to show/cite sound evidence/research that IO devices reduce overall mortality and improve final outcomes....
Also consider that currently the theory of "permissive hypotension" in trauma is being explored, and we may not be in such a rush in the near future for massive fluid volume resuscitations - which means I/O's go back on the shelf and all those Level 1 infusers become good lab coat hooks.
recent ACLS guidelines... of course those are updated and modified based on research, so I'm sure that I/O may be the choice after IV now, but will change down the raod. But it is quicker, second only to IV access. Interesting point about permissive hypotension - take a long time for practice to be changed... of course our Level 1 trauma infuser doesn't work - and most nurses where I work don't even know how to use it!!! They can't get the darn thing operational, which is ridiculous. (personally, I think it's operator error, but that's just me!) Off topic, sorry!
FlyingScot, RN
2,016 Posts