Lynn Phillips, MSN, RN, CRNI

Transcription

1 The Role of Intraosseous Access in Clinical Practice Lynn Phillips, MSN, RN, CRNI Nursing Education Consultant Sponsored by Vidacare Corporation

2 Objectives Identify patients in emergent and non-emergent situations that could benefit from intraosseous (IO) access Review anatomy and physiology Review current IO technologies Discuss the contraindications to IO access. Identify the complications associated with IO access. Discuss the standards of care for IO devices

3 Difficult Vascular Access Is Gaining National Attention Joint Commission Centers for Medicare and Medicaid Services Institute for Healthcare Improvement Public Reporting Dept of Health & Human Services Never Events

4 I Can ALWAYS Get a Line Excessive Tissue Burns Dehydration Renal Patients Sepsis Diabetics Hypertensive Crises C before A? Major Trauma IV Drug Abuser Is it adequate vascular access?

5 Current Options Peripheral IV IntraosseousAccess (IO) Central Venous Line (CVL) Peripherally Inserted Central Catheter (PICC)

6 The Clinical Problem - Time Matters Emergency Department patients with difficult vascular access o 14% of Pediatric Patient Population o 8% of Adult Patient Population Time to establish access o CVC= minutes o PIV = 10 minutes Complications of other access routes

7 Central Venous Lines Complications include Infection Mechanical Thrombotic Economic cost of central venous lines One infection can cost as much as $56,000 Require multiple staff members for placement Requires radiological confirmation of placement

8 PICC Lines Not indicated in emergent patients Lengthy insertion time May require transport to a different department for insertion Radiographic confirmation required before use

9 Who Needs an IO? For adults and pediatrics anytime in which vascular access is difficult to obtain in emergent, urgent or medically necessary cases.

10 It s Been Around How Long? WW II Dr. James Orlowski PALS ACLS Medics helping injured soldier, France, 1944 (208-YE-22). Source: U.S. National Archive

11 Evolution of IO Spinal needles in the sternum o WW II Manual - hand driven o Mainly pediatrics

12 Manual IO Needles Used primarily for pediatrics because their bones are soft Insertion technique can lead to extravasation

13 Evolution of IO Products Spring loaded impact driven o Adults and Pediatrics Powered battery driven o Adults, Pediatrics, Excessive Tissue

14 FAST1 FDA cleared for the sternum in patients 12+ years Impact driven

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16 BIG (Bone Injection Gun) Adult and pediatric FDA cleared for use only at proximal tibia and humerus sites

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18 EZ-IO FDA cleared for proximal humerus, proximal tibia, distal tibia, and patients with excessive tissue on both pediatrics and adults

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20 Modern IO Fast, reliable vascular access Flow rates equivalent to PIV Few complications Historically low infection rate

21 Anatomy of a Long Bone

22 Anatomy of Intraosseous Access Thousands of small vessels lead from the medullary space to the central circulation

23 FDA/CE Cleared Sites Manufacturer dependent o Proximal tibia o Distal tibia o Proximal humerus o Sternum

24 Advantages of IO Allows for rapid intravascular access within one minute IO is mechanically easier to perform than IV Any drug that can be given IV can be given IO Any crystalloid, colloid fluid or blood that can be given IV can be infused by IO Blood samples can be take from bone marrow and used for blood analysis

25 Advantages of IO May be easier to secure and maintain line after insertion when transporting patients Wide range of personnel can perform IO may be the only viable route in Nuclear, Biological or Chemical incidents It is more cost effective compared to placement of central line access

26 Contraindications for IO Access Fracture (targeted bone) Previous orthopedic procedures near insertion site * Prosthetic Limb or joint IO within past 48 hours (targeted bone) Infection at the insertion site Inability to locate landmarks or excessive tissue

27 Complications Infection - Osteomyelitis Extravasation Compartment Syndrome Fracture Operator error Precise insertion and placement of the IO device is imperative for success

28 Who Endorses Intraosseous Access? Nursing Societies o Infusion Nurses Society o Emergency Nurses Association o American Association of Critical-Care Nurses International Resuscitation o American Heart Association o International Liaison Committee on Resuscitation o European Resuscitation Council National Association of EMS Physicians American College of Emergency Physicians

29 INS Position Paper Endorsed by ENA and AACN A qualified registered nurse; appropriately trained for the procedure, may insert, maintain, and remove Intraosseous access devices IO access may provide significant time savings which may benefit critically ill patients, both by decreasing time to achieve access and by decreasing time to administer indicated medication

30 INS Standards of Nursing Practice 2011 IO route may be considered for emergent and nonemergent use in patients is limited or no vascular access and when the patient may be at risk of increased morbidity or mortality if access is not obtained.

31 Risk Management In an era when liability concerns continue to drive many clinical decisions, it is worth noting that delays in treatment are often cited as the proximate cause of injury leading to malpractice claims. Timely Vascular Access is essential

32 Standards of Care and Patient Management Insertion and skin preparation Dwell Time current 24 hours Site Dressing Site Observation Maintaining the IO Cannula

33 Standards of Care and Patient Management Patient Management Pain Insertion Infusion Drug Administration Use of pump Infusion of medications and solutions Discontinuation of therapy

34 Pain Insertion pain 1.5 to 3 on a Likert scale Infusion pain Non expandable cavity

35 Pain Management Consider IO 2% lidocaine without preservatives and epinephrine (cardiac lidocaine) for patients responsive to pain prior to flush. Follow institutional protocols/policies. Medications intended to remain in the medullary space, such as a local anesthetic, must be administered very slowly until the desired anesthetic effect is achieved. *Physician must determine appropriate dosage range

36 Why Lidocaine - Anesthetic vs. Analgesic Pain associated with IO infusion is related to stimulation of pressure sensors (nerve fibers) in the medullary space Lidocaine inhibits stimulation of those sensors and the propagation of signals along the efferent pain fibers Pain management with analgesic agents can cause systemic effects such as respiratory depression Analgesics alter the perception of pain while anesthetics block sensation

37 Required Flush Thick fibrin network Rapid flush Displaces bone marrow No flush no flow

38 Infusion Contrast Studies Patient Variances Intra-medullary Pressure Pressure Delivery System Pressure Bag Pump Rapid Infuser

39 Infusion Videos

40 What Can be Infused? Crystalline and colloid solutions, along with medications that can be safely administered through a peripheral vein can be given safely through an IO IO and IV doses are the same

41 Laboratory Analysis Attach syringe directly to the secured and stabilized hub Draw 2ml for waste Aspirate IO blood for standardized labs May use heparinized syringe Label tubes as IO blood

42 IO Lab Analysis Study Compared lab results between IO and IV in human volunteers The following lab values produced a statistically significant correlation between IO and venous blood: Glucose BUN WBC was higher Creatinine Hemoglobin Total Protein Chloride Hematocrit RBC Albumin Blood gases IO values were between arterial and venous

43 Scientific Proven Advantages: 500 plus articles are cited in the medical literature since 1922 Studies clearly support the use of IO as a safe, reliable, and rapid alternative to difficult IV access Over 20 pharmacokinetic studies in animals & humans indicate IO is equal to IV There are few, if any, procedures that have been studied as extensively or that have as much scientific evidence as intraosseous vascular access.

44 The next section illustrates key studies examining use of IO compared to IV access, different IO sites versus IV, IO versus CVL, and powered EZIO versus the other IO devices

45 Clinical Research 25-patient clinical study Compared the pharmacokinetics of IO vs. IV administration of morphine sulfate in adults Results showed no differences between IO and IV for nearly all pharmacokinetic parameters The results support the bioequivalence of IO and IV administration of morphine in adults Von Hoff DD, Kuhn JG, Burris HA, Miller LJ. Does intraosseous equal intravenous? A pharmacokinetic study. American Journal of Emergency Medicine 2008; 26:31-8

46 Clinical Research T621, Rev B Study of humeral EZ-IO insertion vs. PIV and CVL insertion Mean insertion times EZ-IO 1.5 minutes PIV 4.0 minutes CVL 15.6 min First attempt success rate 80% for EZ-IO vs. 69% for PIV Success rate for EZ-IO after using a longer needle 100% Learned lessons include securing the IO arm and using a longer IO needle Concluded that IO access is the preferred vascular access route and is life saving when PIV or CVL is difficult or impossible Paxton JH, Knuth TE, Klausner HA. Proximal humerus intraosseous infusion: a preferred emergency venous access. Journal of Trauma 2009:67(3):606-11

47 Who is Using the IO Today? The EZ-IO is used in 75% of acute care hospitals 90% EMS Systems 50+ countries worldwide > 800 insertions per day Vidacare Corporation - July 2011

48 How to contact us: Local Representative: Call or for additional clinical or product information