UPMC PASSAVANT Policy Manual TITLE/SUBJECT: IntraOsseous Device POLICY NO: 240.005 DEPARTMENT: Emergency Medicine DATE: April 2015 INDEX TITLE: Dept Specific KEYWORDS: Vascular Access, IO POLICY It is the policy of UPMC Passavant to provide evidence-based care and standards for patients requiring the insertion of an Intraosseous Device (IO) in emergent situations. To assist with this process, Emergency Department and Critical Care Professional Nursing Staff may initiate insertion of the Intraosseous Device based upon the presenting symptoms of the patient. PURPOSE To establish guidelines for the insertion, management, discontinuation, and care of Intraosseus Devices for patients within the emergency departments and critical care units. SCOPE UPMC Passavant Emergency Departments and Critical Care Units RESPONSIBILITY Registered Nurses and Physicians DEFINITIONS Intraosseous (IO): needle device that is placed within the vascular space of the bone marrow for vascular access EQUIPMENT NEEDED Gloves IO Needle Pink Needle- 15mm- recommended for patients 3-39 kg Blue Needle- 25mm- recommended for patients 40kg and greater Yellow Needle- 45mm- recommended for patients with humeral insertion or greater than 40kg with excessive tissue Extension tubing EZ-IO drill IO armband Chloraprep cleaning cloth 10cc syringe of sterile saline (3) 10cc syringe (1-2) blood sample tubes and transfer device 1000ml NS bag/tubing Pressure bag Tape and 4x4 dressings 2% Lidocaine
PROCEDURE I. GENERAL GUIDELINES A. IO access is indicated in emergency situations were vascular access is not available or cannot be quickly obtained B. IO may be considered in non-emergent situations who have limited or no vascular access and patient is at risk of increased morbidity or mortality if access is not obtained. C. IO may be placed in any age patient in a variety of locations, providing key landmarks are palpable D. Preferred IO placement sites include the proximal tibia and proximal humerus in both adult and pediatric patients. E. The EZ-IO is the handheld, battery-operated device that drills the IO needle into the IO space with a high-speed rotary motion. This is the only device approved for insertion. F. Contraindications for IO placement include: pre previously used or attempted IO sites (within 48 hours); fractures at or above the IO site; inability to identify landmarks; previous surgery on the bone, including knee replacements (tibia); presence of infection at the insertion site; obvious infection or deformity over insertion site G. Complications associated with IO access are relatively rare, but could include extravasation from dislodgement, iatrogenic fracture, growth place injury, infection, fat emboli, compartment syndrome, and osteomyelitis H. IO is to be removed by a registered nurse or physician within 24 hours from insertion. I. Patients with emergent IO access established in the emergency department should not be placed on a general medical surgical or progressive/telemetry unit. J. If patient arrives to OR and/or Cath Lab with IO access, alternative access should be placed prior to the patient departing those respective departments. II. INSERTION Guidelines for Nursing Procedure Obtain physician order Verify patient s identification Explain procedure to patient/family if applicable Choose appropriate IO needle/length and assemble equipment Wash hands and don gloves Inspect needle set package to ensure sterility Prime extension tubing with sterile saline or lidocaine as appropriate Palpate site to locate appropriate anatomical landmarks for IO placement. If placing IO in the humerus, ensure that the patient s hand is resting on the abdomen and that the elbow is adducted (wrist over umbilicus or thumb to the bum ) Cleanse site with chloraprep and allow to air dry thoroughly Stabilize IO site, but never hold underneath the insertion site during insertion Remove needle cap and insert the IO needle into the selected site. IMPORTANT: Keep hand and fingers away from the insertion area Remove trocar/ stylet and dispose of in appropriate biohazard sharps container Obtain bone marrow samples for laboratory analysis (if indicated) prior to instilling fluids or medications into the IO Confirm placement by flushing with 5-10 ml normal saline. Fluid should infuse without resistance. Syringe bolus: fast flush the IO catheter with 10 ml of normal saline to displace fibrin mesh inside the bone. (no flush = no flow) Connect primed extension tubing Assess for potential IO complications: swelling of extremity or leakage from IO site Begin IO infusion utilizing a pressure bag. The use of the infusion pump may indicate downward occlusion due to pressure needed to infuse. All secondary medication administration should be administered via piggyback and administered via infusion pump.
The IO should be covered with a sterile dressing after placement Place armband or other identifying marking on patient indicating presence of IO; document time, date, length of catheter and location of placement. Note: Patient should not raise arm above head when IO placed in humerus (such as in CT scan). Keep arm with IO stabilized against the body. (preferred method of utilization of arm sling) III. MAINTENANCE PROCEDURE The IO should be covered with a sterile dressing after placement and while in use. IO site should be monitored at least every 8 hours and also assessed after a patient has been moved. Continue to monitor IO for complications: swelling of extremity or leakage from IO site Note: Patient should not raise arm above head when IO placed in humerus (such as in CT scan). Keep arm with IO stabilized against the body. (preferred method of utilization of arm sling) IV. REMOVAL PROCEDURE Use a 10 ml syringe to remove Attach syringe to IO and simultaneously twist clockwise and pull needle out of the bone Immediately dispose of needle in approved sharps container Insertion site may be covered with a bandage if desired Removal of IO identification armband REFERENCES Alexander, M. (2011). Infusion Nursing Standards of Practice. Journal of Infusion Nursing, 34(1S), S83 American Academy of Pediatrics. (2013). Joint policy statement - guidelines for care of children in the emergency department. Journal of Emergency Nursing, 39(2), 116-27. American Heart Association. (2005). American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care (part 7.2): management of cardiac arrest. Circulation, 112, IV58-IV66. Day, M.W. (2011). Intraosseous devices for intravascular access in adult trauma patients. Critical Care Nurse, 31(2), 76-90. Infusion Nurses Society [position paper]. The role of the registered nurse in the insertion of intraosseous access devices. Journal of Infusion Nursing, 32(4), 187-188. Lewis, G.C., Crapo, S.A., William, J.G. (2013). Critical skills and procedures in emergency medicinevascular access skills and procedures. Emergency Medicine Clinics of North America, 31, 59-86. http://dx.doi.org/10.1016/j.emc.2012.09.006 Vidacare (2013). http://www.vidacare.com/ez-io/index.aspx [manufacture product guidelines] EXECUTIVE SPONSOR: Susan Hoolahan MSN, RN, NEA-BC CNO/VP, Patient Care Services ORIGINAL: January 2014 Reviewed: April 2015 APPROVALS: ED Chairs, Nurse Executive Council, Critical Care Committee PRECEDE: N/A
STEWARD: Clinical Education Specialist, Emergency Medicine