EZ I/O Presentation at FCA


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Presentation by John Peterson at RMH Field Care Audit on 1/18/12. videos are posted on youtube.com/4docmontey

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  • Vidacare employs the concept of the 5 Rights, as this allows the practitioner to easily recall the 5 basic principles of the EZ-IO system.  The 5 Rights are:The Right SiteThe Right NeedleThe Right Pain ManagementThe Right FlushThe Right Amount of Pressure A statement of the 5 rights will be accompanied by a more in-depth explanation of each concept that ensures competent and safe use of the EZ-IO system.   
  • Of course clinicians are good at starting lines in sick people; they do it all the time. Have you ever heard someone say… “I can always get a line”? We can’t let our ego get in the way of what is best for the patient.  
  • Although there are limitations to IO access, these limitations are usually isolated to the placement of the EZ-IO rather than patient type or size.  Contraindications are as follows:Fracture (targeted bone) - If there is a fracture to the bone in which the EZ-IO is to be placed, an alternate site must be chosen. Fluid follows the path of least resistance. If an IO is placed in a fractured bone, the fluid would simply extravasate into the surrounding tissue through the fracture site. In the case of the tibia, if a fracture is present, both the proximal and distal sites are contraindicated as they share the same common pathway inside the bone. However, if the patient has a fractured femur and an intact tibia, the tibial sites can still be used as they are totally separate from the femoral compartment. The qualified practitioner should judge the appropriateness of using the lower extremity for EZ-IO the same as he or she would for any IV or femoral central line. Do not use the EZ-IO if there is a strong possibility of creating vascular compromise.  Previous orthopedic procedures near insertion site: The basic rule of thumb is that if the patient has a surgical scar over a joint; assume a titanium appliance within the joint itself. Even though the EZ-IO Needle Sets are revolutionary, they cannot penetrate titanium. If this is the case, simply select one of the other FDA-cleared insertion sites shown in a subsequent slide. IO within past 24 - 48 hours (targeted bone): Healing from intraosseous insertion generally takes 24 - 48 hours and is defined as the point where another IO can be safely placed at the same anatomical site. By that time, fibrin formation and clotting are sufficient to prevent extravasation through the previous IO hole. Complete healing, to the point where X-ray can no longer detect the hole, usually takes several days or weeks.  Infection at the insertion site: Reported infection rates for traditional IO devices are low. Vidacare does not recommend inserting the EZ-IO through an obvious or documented infection over the insertion site. The EZ-IO must be removed within 24 hours after insertion regardless of the insertion site. Inability to locate landmarks (e.g. due to excessive tissue): If the clinician is unable to locate the landmarks for an insertion site for any reason (including excess adipose tissue), select an alternate identifiable insertion site.
  • Intraosseous needles are placed in the proximal and distal ends (epiphysis) of long bones such as the tibia and humerus due to the thinner compact bone and abundance of cancellous (spongy) bone found at these sites. Within the micro-vasculature inside the medullary space, lies a hyper-coagulable fibrin mesh as well as red and yellow marrow. Since this is the space where all blood cells derive from, we can follow the pathway from the medullary space to the venous system. Within the epiphysis or medullary space lies a vast system of canals that blood and fluid can travel through to reach the central circulation.  The myth often perpetuated is that it takes a long time for fluids, medications, or blood infused into the intraosseous space to reach the central circulation. To the contrary, any fluid instilled into the intraosseous space gains access to the central circulation within just a few seconds.A study out of UTMB in Galveston by Kramer, et al. measured peak serum concentrations of epinephrine and found that epinephrine infused via the intraosseous humeral site has the identical peak serum concentration as if it were instilled via a subclavian central line.1   1Kramer GC, Hoskins SL, Espana J, et al. Intraosseous drug delivery during cardiopulmonary resuscitation: relative dose delivery via the sternal and tibial routes. Acad Emerg Med 2005;12(5):s67. 
  • The EZ-IO is approved to be inserted in 6 anatomical sites. These sites are the right and left proximal tibia, the right and left distal tibia, and the right and left proximal humerus. Site selection is dependent on several factors including:Absence of contraindications such as fracture of the target bone, local infection, inability to locate the landmarks or scar indicative of prior joint surgeryAccessibility of the siteAbility to monitor and secure the site
  • To ensure success with the EZ-IO system, it is imperative you select the right needle for the patient. To maximize a successful insertion, you need to assess the selected insertion site, as well as the patient’s physiologic needs. One misconception is that needles are separated into pediatric, adult and large sizes. In fact, although weight of the patient is one of the criteria for needle selection, selecting the correct Needle Set is based primarily on tissue depth overlying the insertion site. The best way to assess which Needle Set is appropriate for your patient is by assessing tissue depth with your finger or thumb. This is done by palpating the insertion site to get an estimate of the depth of tissue. The amount of tissue at the site may range from virtually none (palpate the tissue overlying one of your knuckles) to excessive (palpate the amount of tissue overlying your femur).  Next, consider any special situations that may require a longer Needle Set such as insertion into the proximal humerus, patients with excessive soft tissue, patients with excessive muscle tissue, or patients with substantial edema. These patients will most likely benefit from using the 45 mm needle to ensure a successful primary insertion cannulation. The final aid in helping select the appropriate length needle is the visualization of at least one black line. With the needle attached to the driver, insert the needle through the skin until the tip rests against the bone at a 90 degree angle. Look at the needle to assure that you can visualize at least one black line above the surface of the skin. If you cannot see a black line, the Needle Set selected is too short to reach the medullary space appropriately . Remove the current Needle Set, discard and use the next larger size.  Paxton JH, Knuth TE, Klausner HA. Humeral head intraosseous insertion: The preferred emergency venous access. Annals of Emergency Medicine 2008;52(4):S58.
  • This video portrays the precision, control, and gentleness of the EZIO vascular access system utilizing the thinnest most delicate object – a raw egg.
  • Any medication that can be safely given through a peripheral vein can safely be infused into the medullary space. Use caution with hypertonic saline solutions of longer than 30 minute duration. Von Hoff DD, Kuhn JG, Burris HA, Miller LJ. Does intraosseous equal intravenous? A pharmacokinetic study. American Journal of Emergency Medicine 2008; 26:31-8.Dubick MA, Kramer GC. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9140581 Hypertonic saline dextran (HSD) and intraosseous vascular access for the treatment of haemorrhagic hypotension in the far-forward combat arena. Ann Acad Med Singapore 1997; 26:64-9.
  • Blood draws for laboratory testing are frequently acquired from the medullary space. Since the cavity within the intraosseous space is lined with a viscous fibrin material, it is important to aspirate and discard 2ml before obtaining a sample for lab analysis. Correlation between medullary samples and venous samples may be done to ensure correct interpretation (label the tubes as IO blood).  Miller L, Philbeck T, Montez D, Spadaccini C. A new study of intraosseous blood for CBC and chemistry profile. Annals of Emergency Medicine 2009; 54(3):S59.
  • Miller L, Philbeck T, Montez D, Spadaccini C. A new study of intraosseous blood for CBC and chemistry profile. Annals of Emergency Medicine 2009; 54(3):S59.
  • Insert the needle set through the skin until you feel the tip of the needle touch the bone. This can be accomplished by powering through the skin and up to the bone or pushing through the skin and up to the bone. At this point you need to verify that you can see one of the black lines on the needle above the surface of the skin prior to powering the driver on. This assures that your Needle Set is long enough to penetrate completely through the compact bone and into the medullary space. 
  • Do not use the cartridge as a sharps container. The EZ-IO stylet will fit into most approved bio-hazard sharps containers. Using the cartridge as a sharps container may result in the inadvertent insertion of a contaminated stylet into a subsequent patient.        
  •  Note: Physician must authorize appropriate dosage range and titration (see Pain Management Bibliography M-220 for information).  The amount of lidocaine required to achieve pain relief in awake and responsive patients may vary based on individual differences and distracting injuries or conditions. Clinical correlation and judgment are required. Vidacare publication M-220 is an annotated bibliography of clinical research studies that address management of IO infusion pain and can be used as a resource for clinicians to determine appropriate dosage range and method of administration.  Philbeck TE, Miller LJ, Montez D, Puga T. Hurt so good; easing IO pain and pressure. JEMS 2010;35(9):58-69. 
  • The intraosseous space is occupied with bone marrow which is held in place by a thick fibrin network. In order to obtain maximum flow rates you must displace this thick fibrin mesh. This is achieved with a rapid 10ml flush with normal saline. The initial flush will be met with inherent resistance as the fibrin mesh is being displaced. This has been described as a similar sensation to pushing D50 or accessing a PICC line or vascular access port that has not been recently accessed. After the first flush of normal saline is given, IO flow rates are easy and rapid. Occasionally, patients require more than one flush or if IO has been saline locked for a prolonged period another flush may be required to obtain maximum flow rates.
  • The EZ-Connect extension set should be primed with saline or 2% lidocaine without preservatives or epinephrine (cardiac lidocaine) if so prescribed. If labs are to be obtained the tubing is not primed as blood will be withdrawn through the tubing. As a reminder, if the patient is responsive to pain the clinician may consider 2% lidocaine without preservatives or epinephrine (cardiac lidocaine) for anesthetic effect prior to the 10ml normal saline flush. Remember NO FLUSH, NO FLOW. If this step is omitted optimal flow rates will not be achieved.
  • The pressure in the medullary space is approximately 1/3 of the patient’s mean arterial pressure. This is important to remember because the pressure outside the bone in the IV bag must be higher than the pressure inside the bone to achieve flow. Therefore, fluids or medications must be delivered under pressure to obtain maximum flow rates. Rapid fluid infusers can be used for aggressive fluid resuscitation.   
  • In review, all patients are entitled to the right size needle, the right insertion site, the right pain management if they are responsive to pain, the right amount of flush and the right amount of pressure to obtain desired flow rates.  
  • The EZ IO driver is manufactured using a non-porous fluid resistant medical-grade plastic; however, it is not fluid proof.For cleaning purposes, the driver should never be submerged in a cleaning solution.The driver should be wiped clean with a moistened cloth or sprayed with an anti-microbial solution. Clean around the drive shaft with a cotton applicator and check to ensure that nothing has attached to the magnetic tip.The driver is then wiped dry, inspected and returned to the carrying case. The trigger guard may also be replaced if no carrying case is utilized. Refer to the Driver’s DFU’s for a more detailed instruction. If your clinical environment requires sterilization the G3 Power Driver can be sterilizedusing the STERRAD 100S, NX Standard cycle, and 100NX Standard cycle. STERRAD® is aproduct of Advanced Sterilization Products, a Johnson and Johnson Company.       
  • Vidacare provides 24/7 live clinical support to our clinical partners utilizing our 800 hotline (800-680-4911) which is featured on our patient wristbands, in addition to our website (www.vidacare.com). Vidacare places tremendous value on direct clinical feedback, so we invite you to visit our website to gain the newest, cutting edge product information as well as provide us with your direct feedback on our products performance.
  • If you have any questions please contact your Clinical Manager, you can find their contact information at www.vidacare.com or by calling 1-866- 479-8500.You may also contact the Director of Clinical Applications, Yvonne Bettis at yvonne.bettis@vidacare.com.
  • EZ I/O Presentation at FCA

    1. 1. The 5 Rights of IntraosseousVascular Access T-430 Rev, G
    2. 2. 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 Pressure T-430 Rev, G
    3. 3. Who Needs an IO?• For adults and pediatrics anytime in which vascular access is difficult to obtain in emergent, urgent or medically necessary cases. T-430 Rev, G
    4. 4. “I Can ALWAYS Get a Line…” • Excessive Tissue • Diabetics • Burns • Hypertensive Crises • Dehydration • “C” before “A”? • Renal patients • Major Trauma • Sepsis • IVDA Is it adequate vascular access? T-430 Rev, G
    5. 5. Contraindications • Fracture to the targeted bone • Previous orthopedic procedure to targeted limb – Prosthetic limb or joint • IO within the past 24 - 48 hours in the targeted bone • Infection at the insertion site • Inability to locate landmarks or excessive tissue T-621, Rev G
    6. 6. Anatomy of Intraosseous AccessThousands of small veins lead from the medullary space to the central circulation. T-430 Rev, G
    7. 7. Real-time Flow Rate Studies T-430 Rev, G
    8. 8. The Right SiteSite selection is dependent upon:• Absence of contraindications• Accessibility of the site• Ability to monitor and secure the site T-430 Rev, G
    9. 9. The Right Needle Selection 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 T-430 Rev, G
    10. 10. Three Needle Sets 5 mm mark or “black line” 15 gauge 15 mm/15g 25 mm/15g 45 mm/15g Length and color are the only differences between Needle Sets T-430 Rev, G
    11. 11. Egg Insertion Video T-430 Rev, G
    12. 12. 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 T-430, Rev G
    13. 13. Laboratory Analysis • Attach syringe directly to the secured and stabilized hub • Draw 2ml for waste or blood cultures • Aspirate IO blood for standardized labs • May use heparinized syringe • Label tubes as IO blood T-430, Rev G
    14. 14. IO Lab Analysis StudyCompared lab results between IO and IV in human volunteers • The following lab values produced a statistically significant correlation between IO and venous blood: - Chloride - Calcium - BUN - Creatinine - Hematocrit - Hemoglobin - Glucose • WBC was higher • Blood gases – IO values were between arterial and venous T-430, Rev G
    15. 15. Confirm and Clean Insertion Site T-430 Rev, F
    16. 16. 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 T-430 Rev, G
    17. 17. T-453 Rev A
    18. 18. Identifying the pediatric EZ-IO insertion site If the Tibial Tuberosity CANNOT be palpated the insertion site is two finger widths below the Patella (and then) medial along the flat aspect of the TibiaThe Tibial Tuberosity can be difficult or impossible to palpate on younger patients
    19. 19. T-453 Rev A
    20. 20. Identifying the pediatric EZ-IO insertion site If the Tibial Tuberosity CAN be palpated the insertion site is one finger width below the Tuberosity (and then) medial along the flat aspect of the TibiaAs patients mature the Tibial Tuberosity becomes easier to identify
    21. 21. 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) T-430 Rev, G
    22. 22. Remove Needle Set Safety Cap T-430 Rev, G
    23. 23. Stabilize Extremity Guard against unexpected patient movement. T-430 Rev, G
    24. 24. oInsert Needle Set at a 90 angle to the bone –insert through the skin until you touch bone T-430 Rev, G
    25. 25. Note that a black line is NOT visible above the skinAppropriate Needle SetSelection Matters! Note that the 5 mm mark is NOT visible above the skin Black line Needle Sizes Consider tissue depth PRIOR to bone insertion T-430 Rev, G
    26. 26. Do not Apply Excessive ForceApply the minimal amount of pressure required to keep the driver advancing straight into the bone. T-430 Rev, G
    27. 27. Remove Driver from Needle Set Stabilize the Needle Set while disconnecting Driver. T-430 Rev, G
    28. 28. Removal of the Stylet • 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 T-430 Rev, G
    29. 29. Put Stylets Where They Belong . . . Portable sharps protector in approved biohazard containers. T-430 Rev, G
    30. 30. Confirm Catheter Placement 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. T-430 Rev, G
    31. 31. Intraosseous Usage and Pain Insertion pain is specific, and of short duration Infusion pain is general, diffuse and protracted T-430 Rev, G
    32. 32. Sometimes it Hurts… • Foley Catheter • IM Injections • Nasogastric Tube • Adhesive Removal • Multiple IV Sticks • Dressing Changes • Central Lines • Wound Debridement • Spinal Taps • Clysis T-430 Rev, G
    33. 33. 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 range T-430 Rev, G
    34. 34. 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 T-430 Rev, G
    35. 35. 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 No Flush = No Flow T-430 Rev, G
    36. 36. 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 T-430 Rev, G
    37. 37. Infuse Fluids with PressureRegulate fluid delivery for ALL patients and take patient condition into account with amounts delivered. T-430 Rev, G
    38. 38. IO Care and Use • Flush with 3-5ml of saline before and after medication administration • The IO space is hypercoagulable and may need to have a continuous flow of fluids and/or may need be flushed several times throughout treatment to avoid clotting • Continually reassess and manage infusion related pain T 463 Rev A
    39. 39. TroubleshootingIf fluids will not infuse:• Disconnect IV tubing from EZ-Connect extension set and flush EZ-Connect with 10ml of saline• To obtain maximum flow rates, infuse with pressure (pressure bag, rapid infuser or pump)• Assure the clamp on the EZ-Connect is open T 463 Rev A
    40. 40. Troubleshooting If fluids will not infuse: • If EZ-Connect appears to be occluded, replace extension set • If infusing with a rapid infuser or pump, troubleshoot the infusion equipment • If unable to restore flow through the IO, or if signs of extravasation or edema develop, remove the IO and replace at an alternative site if IO vascular access is still necessary T 463 Rev A
    41. 41. Troubleshooting If fluids will not infuse: • Consider heparin lock between uses • Consider heparin or urokinase to open blocked IO – Follow your institutional policy for clotted vascular access devices T 463 Rev A
    42. 42. EZ-IO Removal Maintain axial alignment – DO NOT rock the syringeRotate syringe clockwisewhile pulling straight back Back the EZ-IO catheter out of patient while stabilizing the extremity. T-430 Rev, G
    43. 43. Aftercare • Following EZ-IO removal, apply gentle pressure and dress site appropriately • Inform the patient that soreness is normal for up to forty-eight hours following removal • There are no weight bearing or ambulation restrictions following removal of the IO • The patient should be able to assume normal activities as soon as their primary medical condition allows • Notify physician if signs and symptoms of infection develop at or around the insertion site T 463 Rev A
    44. 44. 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 Pressure T-430 Rev, G
    45. 45. 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 DO NOT SUBMERGE DRIVER AT ANY TIME T-430 Rev, G
    46. 46. Clinical Support • Wrist band • 24 hour Emergency Line • 1-800-680-4911 • www.vidacare.com • Web Feedback form T-430 Rev, G
    47. 47. Questions?Please review “Directions For Use” before using the EZ-IO. T-430 Rev, G