SARASOTA MEMORIAL HOSPITAL. NURSING PROCEDURE INTRAOSSEOUS NEEDLE: INSERTION, CARE, AND REMOVAL (inv08) 12/18 12/18 1 of 7 RESPONSIBILITY:

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1 SARASOTA MEMORIAL HOSPITAL TITLE: ISSUED FOR: NURSING PROCEDURE INTRAOSSEOUS NEEDLE: INSERTION, CARE, AND REMOVAL (inv08) Nursing DATE: REVIEWED: PAGES: 12/18 12/18 1 of 7 RESPONSIBILITY: PS1094 Insertion- Code Blue RN, Intervention RN, Rapid Response RN, Main ECC/North Port RN Maintenance-RN Removal- ECC, PACU, Specially Trained Critical Care Nurses or Intervention RN PURPOSE: DEFINITIONS: KEY WORDS: INDICATIONS FOR USE: CONTRAINDICATIONS: KNOWLEDGE BASE: To provide procedural guidance for: insertion, care and maintenance, and removal of the Intraosseous (IO) needle. Intraosseous (IO): situated within, occurring within, or administered by entering a bone. Intraosseous, IO, EZ-IO, infusion, vascular access For adult and pediatric patients anytime vascular access is difficult to obtain in emergent, urgent or medically necessary (non-emergent) cases. 1. Recent fracture of the targeted bone 2. Previous, significant orthopedic procedures at insertion site (e.g. prosthetic limb or joint) 3. IO within the past 48 hours in the targeted bone 4. Infection at area of insertion 5. Excessive tissue or absence of adequate anatomical landmarks 6. The patient cannot have an MRI with an IO in place 1. IO devices are to be removed as soon as alternative access is obtained. An IO device should not remain in place beyond 24 hours. 2. If an IO device is placed in Surgery or Labor and Delivery Room (LDR), an alternative line placement will be established by anesthesia in Surgery/Post-Anesthesia Care Unit (PACU) and the IO catheter will be removed in the PACU. 3. IO devices are to be removed by Emergency Care

2 CARE AND REMOVAL (inv08) Page 2 of 7 Center (ECC), PACU, specially trained Critical Care Nurses or Intervention Nurses. 4. All efforts are to be undertaken to obtain alternative access before a patient with an IO is transferred to a nursing unit. 5. Central or peripheral access is first choice. Assure that the patient has been fully assessed for both peripheral and central access prior to sending the patient with an IO to a nursing unit. 6. If an IO cannot be removed prior to transfer to a nursing unit, the nursing unit is to contact the Intervention Nurse or House Supervisor to obtain assistance with the initial assessment. 7. If a patient MUST be transferred to a nursing unit, an order for alternative access and a timeline for that access MUST be present and communicated to the receiving unit. EQUIPMENT: PROCEDURE: IDENTIFY INSERTION SITE: 1. EZ-IO Vascular Access Power Driver 2. Appropriate length sterile needle set based on clinician s assessment of patient. (All needles are 15ga with varied lengths) 3. EZ-Connect extension tubing (included in sterile needle set package) 4. Non-sterile gloves 5. Chlorhexidine or cleansing agent of choice 6. EZ-Stabilizer (tm) dressing 7. Sterile normal saline for flush. 8. Consider 2% preservative-free IV lidocaine without epinephrine (i.e. cardiac lidocaine,) for patients responsive to pain, per physician order. 9. Intravenous fluid (as indicated) 10. Pressure bag for primary line (a pump may be used for the secondary infusion) 1. Explain procedure to patient/family when possible 2. Obtain assistance as needed 3. Wash hands 4. Prepare syringe with appropriate volume of sterile saline solution for flush 5-10mL for adult 2-5mL for infant/child (adjust volume based on size of patient) Palpate site to locate appropriate anatomical landmarks for needle set placement and to estimate soft tissue depth overlying the insertion site.

3 CARE AND REMOVAL (inv08) Page 3 of 7 Proximal Humerus: 1. Place the patient s hand over the abdomen (elbow adducted and humerus internally rotated) 2. Place your palm on the patient s shoulder anteriorly 3. The area that feels like a ball under your palm is the general target area 4. You should be able to feel this ball, even on obese patients, by pushing deeply 5. Place the ulnar aspect of one hand vertically over the axilla 6. Place the ulnar aspect of the opposite hand along the midline of the upper arm laterally 7. Place your thumbs together over the arm 8. This identifies the vertical line of insertion on the proximal humerus 9. Palpate deeply as you climb up the humerus to the surgical neck a. It will feel like a golf ball on a tee the spot where the ball meets the tee is the surgical neck b. The insertion site is on the most prominent aspect of the greater tubercle, 1 to 2cm above the surgical neck. c. On large patients you may only palpate the most prominent aspect of the greater tubercle 10. If necessary, for further confirmation, locate the inter-tubercular groove: 11. With your finger on the insertion site, keeping the arm adducted, externally rotate the humerus 90- degrees 12. You may be able to feel the inter-tubercular groove 13. Rotate the arm back to the original position for insertion hand over the abdomen 14. The insertion site is 1-2cm lateral to the intertubercular groove Proximal Tibia 1. Insertion site is approximately 2cm below the patella and approximately 2cm medial to the tibial tuberosity (depending on patient anatomy) along the flat aspect of the tibia. 2. Pediatric - If NO tuberosity is present, the insertion is located approximately 2cm below the patella and 1cm medial, along the flat aspect of the tibia. Pinch the tibia between your fingers to identify the medial and lateral borders. Distal Tibia

4 CARE AND REMOVAL (inv08) Page 4 of 7 1. Insertion site is located approximately 2cm proximal to the most prominent aspect of the medial malleolus for adults and 1-2cm proximal for pediatrics. Palpate the anterior and posterior borders of the tibia to assure that your insertion site is on the flat center aspect of the bone. NEEDLE SELECTION: INSERTION PROCEDURE: Select Intraosseous needle set based on patient anatomy, weight and tissue depth Needle selection is dependent on clinical judgment NOTE: The EZ-IO catheter is marked with a black line 5mm proximal to the hub. Adequate needle length is determined by the ability to see the 5mm black line above the skin once the EZ IO needle is inserted. EZ-IO 45mm needle set (yellow hub) should be considered for: -Proximal humerus insertion in patients 40kg and greater -Patients with excessive tissue over any insertion site EZ-IO 25mm needle set (blue hub) should be considered for: -Tibial insertions in patients 40kg and greater or when additional length is needed EZ-IO 15mm needle set (pink hub) should be considered for: -Small pediatric patients -Tibial insertions in patients approximately 3-39 kg caution - consider tissue depth over insertion site 1. Inspect EZ-IO needle set package to ensure sterility 2. Prime EZ-Connect extension tubing with sterile saline or lidocaine as appropriate (priming volume 1.0mL) a. Consider IO 2% preservative free IV lidocaine without epinephrine per physician order, for patients responsive to pain b. Recommended lidocaine dosages per the Lidocaine Administration Flowchart (see attached) 3. Leave syringe attached to EZ-Connect extension tubing 4. Apply clean or sterile gloves 5. Re-confirm insertion site 6. Cleanse site with chlorhexidine, allow to dry 7. Connect appropriate needle set to driver 8. Remove needle cap 9. Stabilize site

5 CARE AND REMOVAL (inv08) Page 5 of Gently push the needle set through the soft tissue at the insertion site until the needle set tip touches the bone 11. Inspect to ensure that at least one black line is visible above the skin. If no black line is visible, consider a longer needle set or an alternative site for insertion 12. Penetrate the bone cortex by squeezing driver s trigger and applying gentle, consistent, steady pressure a. ***Allow the driver to do the work*** 13. Release the driver s trigger and stop the insertion process when: a. Adult patients: the hub is almost flush with the skin b. Pediatric patients: you feel a decrease in resistance indicating the needle set has entered the medullary space - stop when you feel the pop or give 14. Stabilize hub of the needle set with non-dominate hand, remove driver by pulling straight off 15. Continue to stabilize the hub of the needle set and remove stylet by turning top of needle set counterclockwise, then pull stylet up & out, the needle should feel firmly seated in the bone (1 st confirmation of correct placement) 16. Immediately dispose of stylet in appropriate biohazard sharps container 17. Stabilize hub of needle and connect a luer lock syringe directly to the EZ-IO hub 18. Place EZ-Stabilizer (tm) dressing over the needle hub 19. Attach EZ-Stabilizer (tm) dressing by pulling the tabs to expose the adhesive and adhere to skin 20. Aspirate blood or marrow from the catheter. (Inability to aspirate is not always an indication of inappropriate placement) a. Blood/marrow samples obtained from the IO cannot be sent to lab for testing due to possible bone fragments in the sample. 21. Attach primed EZ-Connect extension set to the needle hub, firmly secure by twisting clockwise a. In patients responsive to pain, consider lidocaine (see below) 22. Flush catheter vigorously with 5-10mL normal saline (adults), 2-5mL normal saline (infant/child) /adjust volume based on size of patient 23. Connect fluids (if indicated) and pressurize up to 300mmHg for maximum flow, secure tubing

6 CARE AND REMOVAL (inv08) Page 6 of Humerus ensure arm remains in place, consider application of arm immobilizer (DO NOT abduct the arm, i.e. bring out from the side or over the head) 25. Document date and time on armband and place on patient 26. Consistently monitor site and limb for extravasation or other complications LIDOCAINE DOSING: CATHETER REMOVAL: REFERENCES: Consider using anesthetic for patients responsive to pain: Review manufacturer s lidocaine instructions for use prior to administration and observe recommended cautions/contraindications to using 2% preservative free and epinephrine free lidocaine (intravenous lidocaine) 1. Confirm lidocaine dose per institutional protocol and physician order 2. Prime EZ-Connect extension set with lidocaine 3. Note that the priming volume of the EZ-Connect extension set is approximately 1.0 ml 4. Slowly infuse lidocaine over 120 seconds. a. Adults: Typical initial dose is 40 mg b. Infant/Child: Typical initial dose is 0.5 mg/kg, not to exceed 40 mg 5. Allow lidocaine to dwell in IO space 60 seconds 6. Flush with normal saline a. Adults: 5 to 10 ml b. Infant/Child: 2 to 5 ml 7. Slowly administer an additional dose (if needed) of lidocaine IO over 60 seconds. Repeat PRN a. Adults: Typical dose is 20 mg b. Infant/Child: Half the initial dose 8. Consider systemic pain control for patients not responding to IO lidocaine 1. Remove the EZ-Connect extension set from the needle hub 2. Remove EZ-Stabilizer (tm) dressing 3. Stabilize needle hub and attach a 5-10mL sterile luer lock syringe to act as a handle 4. Grasp syringe, maintaining axial alignment, twist clockwise while gently pulling the needle straight out 5. DO NOT ROCK OR BEND THE NEEDLE DURING REMOVAL 6. Dispose of needle with syringe attached into a sharps container 7. Apply pressure to site as needed to control bleeding and apply dressing as indicated EZ-IO Intraosseous Vascular Access System Procedure. (n.d.). Retrieved from

7 CARE AND REMOVAL (inv08) Page 7 of 7 io/va_ios_ez-ioproceduretemplate_ai_mc docx ARROW EZ-IO Intraosseous Vascular Access System Pain Management. (n.d.) Retreived from io/va_ios_arrow-ez-io-recommended- Anesthetic_AI_MC docx Lidocaine Administration Flowchart. (n.d.). Retreived from For questions, concerns, or complications, call Teleflex s 24 hour toll free Emergency Support Line at: AUTHORS: Aaron McCoy, BSN, RN, TCRN, NPD, ECC Annette Freidhof, MSN, RN, NPD Specialist, ECC APPROVAL: Clinical Practice Council 12/6/18 ATTACHMENT(S):