You're working in the intensive care unit, caring for a 58-year-old patient who was admitted for postoperative management of a liver laceration repair. The cardiac monitor suddenly alarms, and you identify the rhythm as a sinus bradycardia with a rate of 38 beats/minute. You quickly assess the patient, establish unresponsiveness, activate the code team, and determine that the patient is apneic and pulseless. You begin cardiopulmonary resuscitation (CPR) until help arrives.
During the code, someone accidentally dislodges the patient's only I.V. line and no one can reestablish I.V. access. Now what?
In this article, I'll discuss a valuable alternative: intraosseous (IO) access. Intraosseous devices can be used to deliver fluids and medications in an emergency when venous access is unavailable or can't be quickly established. Although IO devices have been used in pediatric resuscitation for years, those for adult use have been available for only about 10 years. The devices I'll describe are approved by the FDA for use in adults (and in one case, for children age 12 and older). Let's start by reviewing how IO access works.
Access that's not in vein
Intraosseous access is achieved via medullary canals in the manubrium of the sternum, humerus, and tibia. These canals are both highly vascular and noncollapsible, a decided advantage in an emergency. In addition, blood flow from the medullary canals enters the central circulation rapidly.
The manubrium, or upper one-third of the sternum, can be easily identified and located and is relatively uniform in size in adults. Easily accessed even during CPR, the manubrium rarely sustains traumatic injury, retains a high proportion of vascular "red" marrow, and has a thin cortical covering that's easily penetrated.
The proximal tibial insertion site is a relatively flat, narrow aspect of the tibia just below the knee. To find this site in an adult, identify the tibial tuberosity, then move 1 to 2 cm medially and 1 cm proximally, toward the patient's head.
Find the humeral head insertion site with the patient supine. Position the selected arm across his abdomen and the hand at the umbilicus. Identify the distal end of the clavicle and move two finger widths down the arm toward the elbow.
Since 2005, the American Heart Association (AHA) guidelines for CPR and emergency cardiovascular care have recommended an IO device as a safe and effective alternative to I.V. administration of both medications and fluids.1 The AHA also considers administering medication via endotracheal tube to be a last resort because evidence supporting its effectiveness is lacking. The fact that IO devices usually can be placed in less than 90 seconds and have up to a 95% success rate, according to manufacturer studies, makes them valuable critical care devices.
Once inserted, IO devices can deliver up to 125 mL/minute of fluid under pressure, more than adequate in any resuscitation situation. They're very stable, and they may be left in place for up to 24 hours or until conventional vascular access is obtained. The placement sites usually don't affect other emergency procedures, such as CPR, endotracheal intubation, or surgical airway placement (cricothyroidotomy).
Placing devices directly into an adult patient's bone is a relatively new responsibility for RNs. As with any invasive procedure, make sure you receive appropriate training before you use an IO device and follow your facility's policies and procedures. Device manufacturers can provide further assistance and training materials for specific products.
Now let's look at the various IO devices, including tips for placement, removal, and precautions. For more details on each device, see the product instructions or visit the manufacturer's Web site. For contraindications to IO access, see When IO access is a no-no.
FAST1
The FAST1 (First Access for Shock and Trauma) was developed by Pyng Medical Corp. of Vancouver, British Columbia, Canada. This device can be inserted into the manubrium in 60 to 90 seconds with less than a 5% failure rate. This device was recently approved by the FDA for use in adolescents age 12 and older. Once established, the FAST1 can maintain a flow rate of 30 mL/minute via a gravity drip and up to 125 mL/minute using a pressure bag.
* Insertion tips. The device must be held perpendicular to the manubrium (not the patient's body) so that the infusion tube is correctly placed. If fluid doesn't flow or leaks at the insertion site, remove the device and try to insert a new one at the same site. If this is also unsuccessful, remove the device and attempt to obtain other vascular access. (For more on using this device, see "Act FAST with Intraosseous Infusion" in the November issue of Nursing2003.)*
* Removal tips. Grasp the infusion tube at the insertion point and pull straight out. Remove the target/strain relief patch, apply pressure, and apply a dry, sterile dressing.
Bone Injection Gun (BIG)
Developed in Israel by WaisMed, Ltd., the BIG device consists of an integrated trocar, a needle set, and its spring-loaded housing unit, which injects the trocar and needle as a unit. When the trocar is removed, the embedded needle is ready to use. Color-coded adult and pediatric versions are available.
* Insertion tips. The BIG device is inserted medial and proximal to the tibial tuberosity, which is somewhat different from the tibial insertion site commonly used in children. The FDA has also approved the BIG device for placement in the humeral head in adults. When inserting this device, don't discard the red safety latch; you need it to secure and remove the BIG device.Precautions. Because the infusion can cause pain for a conscious patient, the manufacturer recommends an initial infusion of 1 to 2 mL of 1% lidocaine before administering fluids or medications. Optimal infusion flow may be reached by using a pressure device around the I.V. bag applying pressures of up to 300 mm Hg. The device should be used for no more than 24 hours or until vascular access can be obtained. Because of the needle's size, it may be used for bone marrow aspiration or for drawing blood samples.
* Removal tips. Remove the tape and red safety device from around the needle. Gently pull and rotate the needle. Alternatively, use the opening in the red safety latch to help grip the needle while you rotate it. Apply a dressing to the insertion site and dispose of the needle in the nearest sharps container.
EZ-IO
The EZ-IO was developed by Vidacare Corp. and the University of Texas Health Science Center at San Antonio. This device is inserted with a handheld, lithium battery-powered mechanical drill or driver. The power driver is reusable; the needle sets (needle and stylet) are single-use. Three needle sets are available: the PD set is for patients weighing 6.6 to 86 pounds (3 to 39 kg) or for those with little tissue over the insertion site; the AD set is for patients weighing 88 pounds (40 kg) or more, or have too much tissue over the insertion site for the PD needle set, and the LD set is for patients with excessive tissue over the insertion site that would preclude using the PD or AD needle sets.
* Insertion tips. The EZ-IO AD (adult device) may be inserted in either the proximal tibia or the humerus.
* Precautions. The device is contraindicated in patients with excessive tissue at the insertion site or the absence of adequate anatomic landmarks. Excessive tissue at the insertion site that would prevent appropriate placement can be easily determined by using the adult device needle set. Remove the needle set's safety cap and insert the needle until you touch bone. If the 5-mm mark is visible, the insertion site is usable.
* Removal tips. Remove the I.V. extension set and attach a 5-mL syringe. Rotate the syringe clockwise to lock it onto the needle hub. Begin gently pulling and rotating clockwise to remove the needle, being careful not to rock it. If the hub separates from the needle, a large needle forceps may be used to grasp and remove the needle, pulling gently and rotating. Dress the site with antibiotic ointment and a sterile bandage.
Help is on the way
Now let's return to the patient we met at the beginning of this article. Following your facility's policies and procedures, you quickly establish IO access and rapidly administer 1 mg of epinephrine, given IO push, and 500 mL of I.V. fluid. The patient responds with an increased heart rate and a barely palpable pulse. You continue to infuse I.V. fluid at a fast rate through the IO device and determine that his abdominal girth has increased. His abdomen is also tense, and the originally dry surgical dressing is saturated with blood. You have one of your coworkers contact the patient's surgeon, who orders an immediate transfusion of four units of packed red blood cells and a unit of platelets. She says that she'll arrive in about 10 minutes and orders that the patient be prepared for surgery.
The patient survives a second surgical procedure to stanch continued bleeding from the liver laceration and is discharged from the hospital 1 week later. Your knowledge of IO devices and their lifesaving role in critical care played a large part in his recovery.
When IO access is a no-no
Check the device package insert for specifics, but in general, IO access isn't recommended if the patient has:
* severe osteoporosis or other conditions that may soften the manubrium
* tissue damage (such as from trauma, infection, or burns) directly over the insertion site
* fractures of the manubrium, a flail chest involving the manubrium, or previous sternotomy
* fractures of the insertion leg or any condition that would compromise the leg's circulation
* extremely small body size as defined by the device manufacturer. Establishing IO access could harm these patients, so weigh the risks and benefits of using the device.
* osteoporosis, Osgood-Schlatter disease, or other diseases or injuries that obscure the tibial tuberosity
* previous orthopedic procedures (IO use within the past 24 hours or prosthetic joint replacement) in the joint closest to the insertion site.
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