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:
1. Before you start - reflection activity
2. 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
3. Practical tips
4. Patient safety tips
5. 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
14. • 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
15. • 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
Safe insertion of an IO needle
16. 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)
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.
