Intraosseous Vascular Access E-Learning Resource

This package should be completed in conjunction with: Knowledge of the Paediatric Surviving Sepsis Guideline IO insertion skill stations (RCH simulation program & skills lab) Disclaimer: This learning package has been developed by The Royal Children's Hospital. The information contained in this package is intended for the use of healthcare professionals only. The Royal Children's Hospital does not accept any responsibility, and will not be liable for, any inaccuracies, omissions, information perceived as misleading, or the success of any treatment regimen detailed in this package. Education packages may not be reproduced without permission.

Introduction This learning resource has five components: Before you start - reflection activity Read and Learn Indications for insertion of an IO needle Safe insertion of an IO needle Risks and complications of IO needle insertion Which drugs and fluids can be administered through an IO needle Practical tips Patient safety tips Resource page should you want further information

Before you start You are involved in the emergency resuscitation of a child who has presented with probable meningococcal sepsis. Two senior doctors are trying to get IV access (to administer antibiotics and volume) but have been unsuccessful and minutes are passing. Would you speak up and suggest an IO should be inserted? Are you confident to do the procedure?

Indications for IO IO line placement should be considered in any emergency situation requiring administration of fluids or drugs where vascular access has not rapidly been obtained (2 attempts or >90 seconds)

Indications for IO To gain emergency vascular access in Cardiac Arrest Deteriorating child Hemodynamic instability Respiratory compromise Altered level of consciousness Trauma

Thousands of small veins lead from the medullary space to the central circulation

Safe insertion of an IO needle Equipment: Non sterile gloves Alcohol swab or dressing pack with Chlorhexadine skin preparation EZ-IO driver and appropriate sized needle 5ml & 20ml syringe Infusion fluid Designed for 1000 human insertions

Prepare Equipment EZ-IO Driver EZ-IO Needle EZ-Connect

Prepare Equipment Length and color are the only differences between paediatric & adult needle sets

IO access sites for pediatric patient Identify site IO access sites for pediatric patient

Proximal Tibial Anatomy The growth plate is of particular interest with regard to pediatric intraosseous placement. There is a great deal of discussion and a substantial body of evidence surrounding the pediatric growth plate. The fear, though unproven, suggests that permanent injury may result from the placement of an IO catheter into the growth plate. At present there are no studies in the literature associating IO placement with growth plate injury. Research in animal models suggests that inadvertent IO placement through the growth plate does not cause any long term deformity or any other complications. Additionally, follow up X-rays in pediatric patients, whose epiphyseal plates had been inadvertently penetrated by IO needles, HAVE NOT demonstrated complications. However, to be prudent you should always maintain a reasonable distance from the growth plate to avoid it’s inadvertent penetration. IO should be inserted 2 cm below tibial tuberosity (away from growth plate)

Proximal Tibial Anatomy

Safe insertion of an IO needle Universal precautions Clean skin at insertion site Choose appropriate sized needle Attach needle to driver (magnetic) Hold needle & driver at 90o to skin and push needle through skin until bone is felt (without engaging driver)

Safe insertion of an IO needle Engage EZ-IO driver to advance needle until there is a give / loss of resistance Detach driver (magnetic) Unscrew trochar Attach 5 ml syringe and aspirate (Aspirate from marrow can be used to check glucose & provide blood cultures, notify lab of BM specimen if sending any other blood tests) Flush to confirm correct position Prime & attach EZ-IO connect

Contraindications for IO Complications of IO Contraindications for IO Extravasation of fluid or medication Fracture of bone above IO site Compartment syndrome Burn at or above insertion site Pain -associated with infusion Cellulitis at insertion site Osteomyelitis Osteogenesis imperfect Growth plate injury Osteopetrosis Minor fractures Inability to locate landmarks or excessive tissue

Complications of IO - pain Minimal pain associated with insertion of EZ-IO fast insertion speed small insertion site vast majority of awake patients can tolerate insertion without local anesthetic. Infusion pain can be severe visceral in nature diffuse can evoke nausea

Which drugs & fluids can be given All resuscitation drugs, fluids and blood products can be administered through an IO

Practical Tips Due to resistance - fluids & drugs need to be PUSHED through an IO Patient Safety Tips IO access provides emergency vascular access. As soon as possible definitive venous access should be obtained & IO removed

Resources for additional reading Surviving Sepsis Campaign Surviving Sepsis – Special considerations in Paediatrics Insertion of Cooks IO needle (u-tube video) Insertion of EZ-IO in an adult (u-tube video)

Certificate of Completion Enter name here has completed the eLearning module “Interosseous insertion” on 6/04/2017