This is a Drill: Evidence Behind IO

drill bit 2

It’s a quiet night in CCT, and you receive a notification from EMS about an elderly, tachycardic and hypotensive patient. When the patient arrives, her airway is intact, and she is altered. EMS was unable to obtain IV access in the field, and the nurse is unable to obtain venous access as well. You attempt twice and are also unsuccessful. The patient is rapidly becoming more unstable and obviously requires access for both fluid and medication. What’s the next step?

The choices here come down to placing a crash central line, an intraosseous (IO) line, or an ultrasound-guided venous line. Traditionally, many providers here would reach for a central line kit; however, mounting evidence suggests that when time is of the essence, placing an IO is quicker and equally effective and may lead to fewer complications. From a practical standpoint, it’s also less likely to require an interruption in chest compressions.

Time

It’s intuitive that an IO is faster to place than a central venous catheter (CVC), and data backs this up. One prospective, observational study involving 79 patients comparing non‐ultrasound-guided crash femoral lines and IOs in the inpatient setting recorded a time to placement of device of an average of 1.2 minutes for IO lines versus 10.7 minutes for CVCs. Moreover, IOs had a 90% first‐pass success rate compared with 37.5% first-pass CVC attempts. The study also demonstrated an increased overall rate of successful placement, fewer attempts required for placement, and fewer kits required for successful placement[i]. Two smaller, similar studies in an ED setting resulted in data that also supports these findings[ii]^{, [iii]}.

Complications

Complications of IO placement include osteomyelitis, cellulitis, skin abscesses, and infiltration and occur in less than 1% of placements[iv]. The current thought is that IOs should be pulled within 24 hours, although preliminary results[v] suggest that up to 48 hours does not lead to more complications.

Contrast this with CVC complications, which from some data occur in as many as 15% of procedures, and include arterial puncture, hematoma, pneumothorax, and venous thrombosis[vi]. Most importantly, the rate of CVC-related bloodstream infection can add up to 33 infections per 1000 catheter-days. These bloodstream infections that then carry as high as a 15-25% mortality rate per infection[vii]!

In the first study referenced aboveⁱ, 48 CVCs were placed; 16 resulted in arterial puncture (4 with significant bleeding) and 1 resulted in bladder puncture. Thirty-one IOs were placed; the 1 serious complication was a patient with a misplaced IO that resulted in extravasation of pressors and surrounding tissue. The only other 2 complications were one IO dislodged in transport and one patient experienced pain upon infusion. In this study, individuals placing each respective device were senior medical residents trained in the placement of both IOs and CVCs.

A few general considerations

If you’re going to place an IO, keep in mind a few contraindications:

Osteomyelitis

Cellulitis over site

Fractured bone

Osteoporosis or osteogenesis imperfecta

Repeat attempts to insert at same site

Compartment syndrome

Recent prior surgeries in area

Burns

Additionally, it’s important to consider flow rate here compared to a peripheral IV or CVC. Below is a table I borrowed from Reddick et al 2011[viii] via Life in the Fast Lane (http://lifeinthefastlane.com/ccc/device-flow-rates):

flow chart

Compare these numbers to those for IOs, which will flow at 16 – 100 ml/min depending on the study, the bone it’s placed in, and the amount of pressure applied. Based on these data, IOs should be considered roughly equivalent to CVCs in terms of flow (both of which are slower than a large bore peripheral IV, but we’re talking about patients with difficult access here).

The take home point:

The studies we have suggest that IOs are quicker when compared to landmark‐guided CVCs and have a better overall success rate. Although there are no good head-to-head comparisons with regards to complications, the complication rate does seem to favor IOs as well. If you’re desperate for access and need it quickly, it may be more beneficial to use the drill than the needle.

Interestingly, according to providers, in the study by Lee, et alⁱ the biggest barrier to use of IOs was timely kit acquisition. Now that you know all the benefits, encourage your team to know where the IO is kept and reach for it often.

For more info, see Dr. Sterling’s April 25^th Morning Report on IOs.

References:

i. Lee PM, Lee C, Rattner P, Wu X, Gershengorn H, Acquah S. Intraosseous versus central venous catheter utilization and perform
ance during inpatient medical emergencies. Crit Care Med. 2015 Jun;43(6):1233-8. doi: 10.1097/CCM.0000000000000942

ii. Leidel BA1, Kirchhoff C, Bogner V, Stegmaier J, Mutschler W, Kanz KG, Braunstein V. Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Saf Surg. 2009 Oct 8;3(1):24. doi: 10.1186/1754-9493-3-24

iii. Leidel BA1, Kirchhoff C, Bogner V, Braunstein V, Biberthaler P, Kanz KG. Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins. Resuscitation. 2012 Jan;83(1):40-5. doi: 10.1016/j.resuscitation.2011.08.017. Epub 2011 Sep 3.
vi. Petitpas F1,2, Guenezan J3, Vendeuvre T4, Scepi M2,5, Oriot D2,6, Mimoz O1,5 Use of intra-osseous access in adults: a systematic review. Crit Care. 2016 Apr 14;20(1):102. doi: 10.1186/s13054-016-1277-6.
vii. Overbaugh R, Davlantes C, Miller L, Montez D, Puga T, Intraosseous Vascular Access Catheter Appears Safe During Extended Dwell: A Preliminary Report, Annals of Emergency Medicine. October 2015:66(4S):5-6.

viii. Taylor RW, Palagiri AV. Central venous catheterization. Crit Care Med. 2007 May;35(5):1390-6.

ix. Lemaster CH, Agrawal AT, Hou P, Schuur JD. Systematic review of emergency department central venous and arterial catheter infection. Int J Emerg Med. 2010 Nov 5;3(4):409-23. doi: 10.1007/s12245-010-0225-5.
x. Reddick AD, Ronald J, Morrison WG. Intravenous fluid resuscitation: was Poiseuille right? Emerg Med J. 2011 Mar;28(3):201-2. Epub 2010 Jun 26.