Post on 11-Jan-2016
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The 5 Rights of Intraosseous Vascular Access
T-430 Rev, FLinda Arapian RN MSN
MCFRS
The 5 Rights of the EZ-IO
1. The Right Site
2. The Right Needle
3. The Right Pain Management
4. The Right Flush
5. The Right Amount of PressureT-430 Rev, G
Who Needs an IO?
• For adults and pediatrics anytime in which vascular access is difficult to obtain in emergent, urgent or medically necessary cases.
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Maryland Medical Protocols July 2011
• INDICATIONS FOR IO – Cardiac arrest, OR– Profound hypovolemia, OR– No available vascular access, or following two unsuccessful
peripheral IV attempts for patients with..life-threateningillness or injury requiring immediate pharmacological orvolume intervention, OR
- In pediatric patients in cardiac arrest, go directly to IO if no peripheral sites are obvious and without having to attempt
peripheral access
Contraindications
• Fracture to the targeted bone
• Previous orthopedic procedure to targeted limb– Prosthetic limb or joint
• IO within the past 48 hours in the targeted bone
• Infection at the insertion site
• Inability to locate landmarks or excessive tissue
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Maryland Medical Protocols July 2011Contraindications
ADDITIONAL Contraindications for IO placement:
• Conscious patient with stable vital signs
• Peripheral access readily available
Thousands of small veins lead from the medullary space to the central circulation.
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Anatomy of Intraosseous Access
The Right Flush
• The IO space is filled with a thick fibrin mesh
• The medullary space must be pressure flushed to obtain maximum flow rates
• 10ml of normal saline is required for initial bolus
• Flush must overcome initial resistance felt with bolus administration
• More than one flush may be required to achieve maximum flow rate
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The Right Site
Site selection is dependent upon:
• Absence of contraindications
• Accessibility of the site
• Ability to monitor and secure the site
NOTE: Sternum is NOT a site
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Maryland Medical Protocols July 2011Acceptable Sites
Manual placement• Under 6yo – proximal tibia site• Over 6 yo – distal tibia site
Mechanical Placement• 3-39 Kg - proximal tibia• > 40 Kg - adult needle in proximal tibia• > 40 Kg - adult needle in distal tibia (needle length)• > 40 Kg - use proximal humerus if lower extremity
notavailable
- proximal humerus not approved < 40 Kg
Confirm and Clean Insertion Site
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Length and color are the only differences between Needle Sets
25 mm/15g 45 mm/15g
5 mm mark or
“black line”
15 mm/15g
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15 gauge
Three Needle Sets
The Right NeedleSelection based on:
• Needle Length (15 mm, 25 mm, and 45 mm)• Soft tissue depth estimated by using your finger• Visualization of a black line after penetration of the skin• The 45 mm needle should be considered for all proximal
humerus insertions – patients >40 kg• Special situations
– Excessive soft tissue– Excessive muscle tissue– Edema
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Note that the 5 mm
mark is NOT visible
above the skin
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Appropriate Needle Set
Selection Matters!
Note that a black line is NOT
visible above the skin
Needle Sizes
Consider tissue depth PRIOR to bone insertion
Black line
Prepare Equipment
• Inspect needle packaging for damage and sterility
• Open EZ-Connect and prime w/saline (or consider 2% lidocaine for patients responsive to pain)
• Leave syringe attached to EZ-Connect
• Open package and attach Driver to Needle Set (leave cap on needle until ready to insert)
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Remove Needle Set Safety Cap
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Stabilize Extremity
Guard against unexpected patient movement. T-430 Rev, G
Insert Needle Set at a 90o angle to the bone – insert through the skin until you touch bone
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Apply the minimal amount of pressure required to keep the driver advancing straight into the bone.
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Do not Apply Excessive Force
Pediatric EZ-IO Insertion• Pediatric insertion requires a
gentle grip and a soft touch
• One size does not fit all - Consider tissue depth in needle
selection
• Be cautious of driver recoil - Release the trigger when you
feel the lack of resistance
• The EZ-Stabilizer is highly recommended on newborns and infants
Cau
tion
!
Cau
tion
!
Recoi
l!
Recoi
l!
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Remove Driver from Needle Set
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Stabilize the Needle Set while disconnecting Driver.
• Stabilize Needle Set and rotate the stylet counter-clockwise
• Remove stylet and dispose of in approved bio-hazard sharps container
• Apply EZ-Stabilizer before attaching the primed EZ-Connect
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Removal of the Stylet
Portable sharps protector
Put Stylets Where They Belong . . .
in approved biohazard containers.T-430 Rev, G
Note one or more of the following:
• Firmly seated catheter
• Flash of blood in the catheter hub or blood on aspiration *
• Pressurized fluids flow without difficulty
• Pharmacologic effects
* may or may not be able to aspirate blood
Monitor for signs of extravasation.
Confirm Catheter Placement
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No Flush = No Flow
Syringe FLUSH Catheter• Prime and use extension set
• Flush IO catheter with 10ml of saline
• Reminder: For patient’s responsive to pain consider 2% lidocaine without preservatives or epinephrine (cardiac lidocaine) via the IO PRIOR to syringe flush
• Some patients may require multiple syringe flushes
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What Can be Infused?
• Any medication that can be safely given through a peripheral vein can be given safely through an IO
• IO and IV doses are the same
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Intraosseous Usage and Pain
Insertion pain is specific,
and of short duration
Infusion pain is general,
diffuse and protracted T-430 Rev, G
Pain Management
• Consider IO 2% lidocaine without preservatives or epinephrine (cardiac lidocaine) for patients responsive to pain prior to flush. Follow institutional protocols/policies.
• Medications intended to remain in the medullary space, such as a local anesthetic, must be administered very slowly until the desired anesthetic effect is achieved.
*Physician must determine appropriate dosage rangeT-430 Rev, G
Maryland Medical Protocols July 2011Pain Management
Pain due to IO infusion:
Adults administer 20-40 mg of 2% cardiac lidocaine (1-2 mL 2% Lidocaine) IO
Ped > 40Kg administer 20-40mg of 2% cardiac lidocaine (1-2 mL 2% Lidocaine) IO
Peds < 40Kg Medical consultation is required
Regulate fluid delivery for ALL patients and take patient condition into account with amounts delivered.T-430 Rev, F
• The pressure in the medullary space is approximately 1/3 of the patients arterial pressure
• Pressurizing fluids for infusion is required to obtain maximum flow rates
• For aggressive fluid resuscitation a rapid infuser may increase flow rates
Regulate fluid delivery for ALL patients and take patient condition into account with amounts delivered.T-430 Rev, G
Infuse Fluids with Pressure
Clinical Support
• Wrist band
• 24 hour Emergency Line • 1-800-680-4911
• www.vidacare.com
• Web Feedback form
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EZ-IO Removal
Back the EZ-IO catheter out of patient while stabilizing the extremity.
Maintain axial alignment – DO
NOT rock the syringe
Rotate syringe clockwise while
pulling straight back
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DO NOT SUBMERGE DRIVER AT ANY TIME
Cleaning & Disinfecting• Wipe clean with moistened cloth
• Spray with anti-microbial solution
• Momentarily depress trigger several times during cleaning
• Clean around drive shaft with cotton applicator – check to ensure nothing has attached to the magnetic tip
• Wipe dry
• Inspect driver and return to case or replace trigger guard
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VIDACARE Regional Clinical Contact:
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Please review “Directions For Use” before using the EZ-IO.
Karen Hust RN MSN CEN
Clinical Manager - Mid-Atlantic Territory
(NJ, PA, DE, Washington DC, VA, WV, NC)
912-308-1839
Immediate Vascular Access…
When You Need It Most
www.vidacare.com
The 5 Rights of the EZ-IO Review
1. The Right Site
2. The Right Needle
3. The Right Pain Management
4. The Right Flush
5. The Right Amount of PressureT-430 Rev, G
Questions?
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Please review “Directions For Use” before using the EZ-IO.
The Right Amount of Pressure
• The pressure in the medullary space is approximately 1/3 of the patients arterial pressure
• Pressurizing fluids for infusion is required to obtain maximum flow rates
• For aggressive fluid resuscitation a rapid infuser may increase flow rates
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“I Can ALWAYS Get a Line…”
• Excessive Tissue
• Burns
• Dehydration
• Renal patients
• Sepsis
• Diabetics
• Hypertensive Crises
• “C” before “A”?
• Major Trauma
• IVDA
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Is it adequate vascular access?