1. Intraosseous Vascular Access
E-Learning Resource

2. 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.

3. 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

4. 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?

5. 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)

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

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

8. 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

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

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

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

12. 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)

13. Proximal Tibial Anatomy

14. 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)

15. 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

16. 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

17. 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

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

19. 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

20. 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)

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