intraosseous (io) access and cannulation

Intraosseous (IO) Access and Cannulation

Reference Number: NCAM003(19) Version Number: 1.1 Issue Date: 26/02/2020 of 19

It is your responsibility to check on the intranet that this printed copy is the latest version


Lead Author: Luke Winterbourne, Resuscitation Practitioner

Additional author(s): Harriet Ellis, Lead Resuscitation Practitioner

Division/ Department: Resuscitation and Simulation Training Team, Learning and

Development

Applies to: Salford Royal Care Organisation

North Manchester Care Organisation

Bury & Rochdale Care Organisation

Oldham Care Organisation

Northern Care Alliance Group

Date approved: 14th February 2019

Date Amendment approved: 12th February 2020

Expiry date: 14th February 2022

Contents

Contents

Section Page

1 What is the policy about? 2

2 Where will this document be used? 2

3 Why is this document important? 2

4 What is new in this version? 2

5 What is the Policy? 2

5.1 Protocol 3

5.2 Equipment 3

5.3 Selecting site for IO Access 4

5.4 Insertion/Removal of IO device 6

5.5 Use of local anaesthetic 8

6 Roles and responsibilities 9

7 Monitoring document effectiveness 10

8 Abbreviations and definitions 10

9 References and Supporting Documents 10

10 Document Control Information 12

11 Equality Impact Assessment (EqIA) screening tool 13

12 Appendices 15 Appendix 1 Difficult Vascular Access Algorithm 16 Appendix 2 Administration of 2% Lidocaine 17 Appendix 3 Locations of 2% Lidocaine 18 Appendix 4 Locations of EZ-IO Access Kits 19

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)

Pennine Acute Hospitals NHS Trust (PAT)




1. What is this policy about? 1.1 This policy covers the use of intraosseous (IO) access devices, including site selection,

insertion and removal of IO access. Guidelines relating to use of local anaesthetic for patients responsive to pain are also included.

If you have any concerns about the content of this document please contact the author or advise the Document Control Administrator.

2. Where will this document be used?

2.1 The document covers the use of IO access across all of the Northern Care Alliance. 2.2 Policy covers use for both adult and paediatric patients.

3. Why is this document important?

3.1 In the event of failed vascular access, IO access can be used to deliver life-saving medications, fluids and blood products.

3.2 No national legislation or other standards are relevant to this document.

4. What is new in this version?

4.1

Updated guidance relating to the use of local anaesthetic for patients responsive to pain.

Updated guidance from manufacturer relating to insertion and site selection.

Updated locations of EZ-IO access kits and updated contents of access kits.

This policy (NCAM003 Intraosseous (IO) Access and Cannulation) replaces the previous policy of the same name (TWCG14(15) Salford Care Organisation only). This policy now covers all of the Northern Care Alliance.

4.2 V1.1 Appendix 4 updated

5. Policy

5.1 Intraosseous (IO) placement is an accepted standard for vascular access when peripheral intravenous cannula placement is difficult or impossible. IO access can be rapidly inserted (with excellent success rates) and used for the administration of medications, fluids and blood products. Resuscitation Council (2015) Guidelines recommend the IO route if IV access is difficult or impossible. To ensure that the Northern Care Alliance maintains standards for IO therapy in accordance with manufacturer and professional guidelines, the EZ-IO® vascular access system by Teleflex has been adopted.




5.1 Protocol

5.1.1 Indications An immediate need for rapid fluid, drug or blood administration, where IV access is difficult or impossible. Appendix 1 shows the difficult vascular access algorithm.

5.1.2 Contraindications

Fracture in the target bone

Previous, significant orthopaedic surgery at the insertion site, prosthetic limb or joint.

IO in past 48 hours in the target bone

Infection at the area of insertion

Excessive tissue (severe obesity) and/or absence of adequate anatomical landmarks

5.1.3 Cautions The stylet and cannula are not MRI compatible 5.1.3 Complications The following are potential complications and should be observed for:

Extravasation

Compartment syndrome

Infection/osteomyelitis

Penetration through posterior cortex of bone

Cannula bending or clogging

Difficulty removing cannula

5.2 Equipment

5.2.1 EZ-IO® Power Driver The EZ-IO® Power Driver is a sealed, hand-held, non-rechargeable lithium-battery powered medical drill capable of upward of 500 needle insertions.

5.2.2 EZ-IO® Needle Sets

Needle sets are available in three lengths. The patient’s weight and anatomy should be considered when selecting a needle set;

15mm (pink) hub (3-39kg patients)

25mm (blue) hub (≥3kg patients)

45mm (yellow) hub (humeral head insertion in patients ≥40kg and/or excessive tissue over other insertion sites)

Red needles are non-sterile and for training only. Each needle set pack contains the following items:

Needle set

EZ-Connect® extension set

Needle VISE® sharps disposal device

Patient wrist band




5.2.3 EZ-Stabilizer Dressing

After insertion of the EZ-IO, the EZ-Stabilizer dressing should be used to secure and protect the needle from accidental dislodgement.

5.2.4 Other equipment required

10ml 0.9% Sodium Chloride flush

Sterile 10ml luer-lock syringe

Non-sterile latex free gloves

Frepp (2% chlorhexidine gluconate in 70% isopropyl alcohol)

Clean blue ANTT tray

3-way tap/50ml syringe (for insertion of drugs)

Pressure bag (for insertion of fluids) For removal of device

Sterile gauze

Tape/clear dressing

Sharps container

50ml luer-lock syringe

5.3 Selecting site for IO access

5.3.1 The humeral head is the preferred site for insertion as it offers the following benefits

Average flow rate of 5L/hour¹

Lower insertion and infusion pain¹

Less medication required for patient pain management¹

Medication and fluid reach the heart in three seconds²

Proximal and distal tibia are alternate sites in adults. Distal femur, proximal and distal tibia, and proximal humerus are insertion sites in paediatric patients, as illustrated below.

³

1. Philbeck et al, 2010 2. Vida care, 2013 3. Telecare, 2015




5.3.2 Insertion site identification

ADULT INSERTION SITE IDENTIFICATION Proximal Humerus (Adult) 1. Place the patient’s hand over the abdomen (elbow adducted and humerus internally rotated)

2. Place your palm on the patient’s shoulder anteriorly; the “ball” under your palm is the general

target area

You should be able to feel this ball, even on obese patients, by pushing deeply

3. Place the ulnar aspect of your hand vertically over the axilla and the ulnar aspect of your

other hand along the midline of the upper arm laterally

4. Place your thumbs together over the arm; this identifies the vertical line of insertion on the

proximal humerus

5. Palpate deeply up the humerus to the surgical neck

This may feel like a golf ball on a tee – the spot where the “ball” meets the “tee” is the

surgical neck

The insertion site is 1 to 2 cm above the surgical neck, on the most prominent aspect

of the greater tubercle

Proximal Tibia (Adult) 1. Extend the leg.

2. Insertion site is approximately 2 cm medial to the tibial tuberosity, or approximately 3 cm

below the patella and approximately 2 cm medial, along the flat aspect of the tibia.

Distal Tibia (Adult) 1. Insertion site is located approximately 3 cm proximal to the most prominent aspect of the

medial malleolus.

2. Palpate the anterior and posterior borders of the tibia to assure insertion site is on the flat

centre aspect of the bone.

INFANT/CHILD INSERTION SITE IDENTIFICATION Distal Femur (Infant/Child) 1. Secure the leg out-stretched to ensure the knee does not bend.

2. Identify the patella by palpation. The insertion site is just proximal to the patella (maximum 1

cm) and approximately 1-2 cm medial to midline.

Proximal Humerus (Infant/Child) 1. Place the patient’s hand over the abdomen (elbow adducted and humerus internally rotated)

2. Place your palm on the patient’s shoulder anteriorly; the “ball” under your palm is the general

target area

You should be able to feel this ball, even on obese patients, by pushing deeply

3. Place the ulnar aspect of your hand vertically over the axilla and the ulnar aspect of your

other hand along the midline of the upper arm laterally

4. Place your thumbs together over the arm

This identifies the vertical line of insertion on the proximal humerus




5. Palpate deeply up the humerus to the surgical neck

This may feel like a golf ball on a tee – the spot where the “ball” meets the “tee” is the

surgical neck

The insertion site is 1 to 2 cm above the surgical neck, on the most prominent aspect

of the greater tubercle

Proximal Tibia (Infant/Child) 1. Extend the leg. Pinch the tibia between your fingers to identify the medial and lateral

borders.

2. Insertion site is approximately 1 cm medial to the tibial tuberosity, or just below the patella

(approximately 1 cm) and slightly medial (approximately 1 cm), along the flat aspect of the

tibia.

Distal Tibia (Infant/Child) 1. Insertion site is located approximately 1-2 cm proximal to the most prominent aspect of the

medial malleolus.

2. Palpate the anterior and posterior borders of the tibia to assure insertion site is on the flat

centre aspect of the bone.

5.4 Insertion/Removal of IO device

5.4.1 Directions for use (Teleflex, 2014)

1. Explain procedure to patient/family when possible 2. Obtain assistance as needed 3. Wash hands and use a clean “no touch” technique 4. Prepare supplies 5. Palpate site to locate appropriate anatomical landmarks for needle set placement and to

estimate soft tissue depth overlying the insertion site. Utilize the correct technique below based on patient and site selected

6. Prepare site by using frepp to clean the area 7. Remove the needle set cap

ADULT INSERTION TECHNIQUE Proximal Humerus - Adult 1. Aim the needle set at a 45-degree angle to the anterior plane and posteromedial

2. Push the needle set tip through the skin until the tip rests against the bone

The 5 mm mark must be visible above the skin for confirmation of adequate needle set length

3. Gently drill into the humerus approximately 2 cm or until the hub is close to the skin; the hub

of the needle set should be perpendicular to the skin

Tibia - Adult 1. Aim the needle set at a 90-degree angle to the bone


The 5 mm mark must be visible above the skin for confirmation of adequate needle set length




3. Gently drill, advancing the needle set approximately 1-2 cm after entry into the medullary

space or until the needle set hub is close to the skin

INFANT/CHILD INSERTION TECHNIQUE Proximal Humerus – Infant/Child 1. Aim the needle set tip at a 45-degree angle to the anterior plane and posteromedial


The 5 mm mark must be visible above the skin for confirmation of adequate needle

set length

3. Gently drill, immediately release the trigger when you feel the loss of resistance as the

needle set enters the medullary space; avoid recoil – do NOT pull back on the driver when

releasing the trigger

Femur and Tibia – Infant/Child 1. Aim the needle set at a 90-degree angle to the bone


The 5 mm mark must be visible above the skin for confirmation of adequate needle

set length

3. Gently drill, immediately release the trigger when you feel the loss of resistance as the

needle set enters the medullary space; avoid recoil – do NOT pull back on the driver when

releasing the trigger

INSERTION COMPLETION 1. Hold the hub in place and pull the driver straight off; continue to hold the hub while twisting

the stylet off the hub with counter clockwise rotations; catheter should feel firmly seated in

the bone (1st confirmation of placement);

Dispose of all sharps and biohazard materials using standard biohazard practices and disposal containers.

If using the NeedleVISE® 1 port sharps block, place on stable surface and use a one-handed technique.

2. Place the EZ-Stabilizer® Dressing over the hub

3. Attach a primed extension set to the catheter hub, firmly secure by twisting clockwise

4. Pull the tabs off the dressing to expose the adhesive, apply to the skin

5. Aspirate for blood/bone marrow (2nd confirmation of placement) Inability to withdraw/aspirate

blood from the catheter hub does not mean the insertion was unsuccessful.

6. Use local anaesthetic, if required, as detailed in section 5.5

7. Connect fluids if ordered and pressurize up to 300 mmHg for maximum flow

8. Verify placement/patency prior to all infusions. Use caution when infusing hypertonic

solutions, chemotherapeutic agents, or vesicant drugs.

9. Stabilize and monitor site and limb for extravasation or other complications

For proximal humerus insertions, apply arm immobilizer or other securement device For distal femur insertions, maintain securement of the leg to ensure the knee does not bend 10. Document date and time on wristband and place on patient




REMOVAL TECHNIQUE 1. Remove extension set and dressing

2. Stabilize catheter hub and attach a Luer lock syringe to the hub

3. Maintaining axial alignment, twist clockwise and pull straight out

Do not rock the syringe

4. Dispose of catheter with syringe attached into sharps container

5. Apply pressure to site as needed to control bleeding and apply dressing as indicated

5.5 Use of local anaesthetic

5.5.1 For patients who are responsive to pain, local anaesthetic can be considered in adult and paediatric patients.

Review manufacturer’s lidocaine instructions for use prior to administration and observe

recommended cautions/contraindications to using 2% preservative and epinephrine free lidocaine (IV lidocaine)

Appendix 2 shows the flowchart for the administration of lidocaine Appendix 3 shows the location of 2% lidocaine in the Salford Royal care organisation 5.5.2 Anaesthetic for adult patients

1. Confirm lidocaine dose

Typical initial (adult) dose is 40mg

2. Prime EZ-Connect® extension set with lidocaine

Note that the priming volume of the EZ-Connect® extension set is approximately

1.0 mL

3. Slowly infuse lidocaine (typically 40 mg) IO over 120 seconds

4. Allow lidocaine to dwell in IO space 60 seconds

5. Flush with 5-10 mL of normal saline

6. Slowly administer an additional dose of lidocaine IO (typically 20 mg) over 60 seconds

Repeat PRN

Consider systemic pain control for patients not responding to IO lidocaine

5.5.3 Anaesthetic for paediatric patients

1. Confirm lidocaine dose

Typical initial dose is 0.5 mg/kg, not to exceed 40 mg

2. Prime EZ-Connect® extension set with lidocaine

Note that the priming volume of the EZ-Connect® extension set is approximately

1.0 mL.

For small doses of lidocaine, consider administering by carefully attaching syringe

directly to needle hub (prime EZ-Connect® extension set with normal saline).

3. Slowly infuse lidocaine IO over 120 seconds

4. Allow lidocaine to dwell in IO space 60 seconds

5. Flush with 2-5 mL of normal saline

6. Slowly administer subsequent lidocaine (half the initial dose) IO over 60 seconds




Repeat PRN

Consider systemic pain control for patients not responding to IO lidocaine

6. Roles and responsibilities

6.1 Ward Managers, Department Managers and Consultant Managers will:

Ensure that all staff who insert IO cannulas receive training and where practicable complete competence in IO cannulation.

Ensure Staff who administer IO therapy have adequate cover for Hepatitis B. If Practitioners do not have cover, they must be referred to Occupational Health.

Ensure the required notices that comply with Sharps Injury Prevention Procedure are displayed in their areas to inform employees on procedures to be followed after accidental/incident involving exposure to body fluids.

Matrons, Ward Managers and Clinicians will be expected to ensure that staff comply with this policy and monitor practice on an on-going basis using the Saving Lives tools.

Matrons, Ward Managers and Clinicians will be expected to ensure that staff who perform IO insertion undertake mandatory ANTT training and are assessed annually.

6.2 Individual staff that insert, care for or remove intraosseous cannulas must:

Have knowledge of local policies and procedures, specifically; ANTT Policy, Venepuncture in Adults Policy, Preparation and Administration of Intravenous Drugs and Infusions Policy, Peripheral Cannulation in Adults, Latex Allergy Policy, COSHH regulations, and Flushing a Vascular Access Device Policy.

Understand their legal and professional responsibilities.

Have a working knowledge of anatomy and physiology of IO cannulation sites.

If unsuccessful after two IO insertion attempts, ask for a more experienced practitioner to make further attempts.

Understand the relevant policies on Intraosseous Cannulation.

Receive education/training before utilising and attend refresher education/training as required.

Take responsibility for arranging further education/training to maintain and increase competency within the work place.

Practice in accordance with their professional duties.

Practice standard precautions.

Practice an aseptic technique.

Follow the relevant Sharps Injury Prevention Procedures.

Delegate to a more experienced practitioner if they are not competent to insert, maintain or remove intraosseous access

7. Monitoring document effectiveness

7.1

Key standards: all staff trained in ALS will be taught how to use the EZ-IO device. All crash calls are audited by the resus team to identify any antecedence, and use of IO access can be audited at this point if required. Location of equipment and compliance with monthly checks of equipment are completed quarterly by the resus team.




Method(s): Competency assessments completed as part of ALS course. Quarterly audits are completed on crash trolleys by the Resus practitioner’s and a monthly check completed locally in all clinical areas.

Team responsible for monitoring: Resuscitation and Simulation Team (Learning and Development)

Frequency of monitoring: Audits relating to individual patient completed for every 2222 call. Monthly and quarterly audits of equipment.

Process for reviewing results and ensuring improvements in performance: Resus team’s audits used to create quarterly and annual reports which are shared with the Clinical Effectiveness Committed. Adverse incident reporting used if required following antecedence audits and equipment audits. Adverse incident reports are shared with the Clinical Effectiveness Committee on a quarterly and annual basis.

8. Abbreviations and definitions

8.1 IV - Intravenous IO - Intraosseous

9. References and Supporting Documents

9.1 References Philbeck TE, Miller LJ, Montez, D and Puga, T. (2010). Hurts so good; easing IO pain and pressure. JEMS 2010;35(9):58-69 Teleflex (2015). Clinical Resource: Care, maintenance and removal. Teleflex. (2015). EZ-IO® Intraosseous Vascular Access Needles. Teleflex Medical, Ireland. Teleflex. (2014). Arrow® EZ-IO® Intraosseous Vascular Access System Procedure Template. Teleflex Medical, USA. Vida care (2013). Vida care Internal Studies, from Teleflex Clinical Resource: Care, maintenance and removal.

9.2 Related SRFT/PAT documents

IV3(08) – Issue No 7 – Peripheral Cannulation policy in Adults (SRFT policy) IV4(09) – Issue No 6 – Preparation and Administration of Intravenous Drugs and Infusions (SRFT policy) RM7 – Issue No 6 – Resuscitation Policy (SRFT policy) CL9 – V7.1 – Resuscitation Policy (Pennine Care policy)

9.3 Acknowledgement of sources

Images and text courtesy of Teleflex clinical resources website, who are happy for the reproduction of their resources (https://www.teleflex.com/usa/clinical-resources/ez-io/

https://www.teleflex.com/usa/clinical-resources/ez-io/




10. Document Control Information

It is the author’s responsibility to ensure that all sections below are completed in relation to this version of

the document prior to submission for upload. Remove instructions once completed.

Nominated Lead author:

Name Luke Winterbourne

Role Resuscitation and Simulation Practitioner/ Emergency Department Nurse

Lead author contact details:

Full contact telephone number 0161 206 0196

Full trust email address [email protected]

Lead Author’s Manager:

Name Harriet Ellis

Role Lead Resus Practitioner, Project transition Lead NCA

Applies to: All care organisations within Northern Care Alliance

Salford CO

Oldham CO

North Manchester

CO

Bury & Rochdale

CO

Northern Care Alliance Group (NCA)

Document developed in consultation with :

Harriet Ellis (Lead Resuscitation Practitioner, Northern Care Alliance)

Ian MacDougall (Senior Resuscitation Practitioner, Fairfield Care Organisation)

Susan Buckley (Senior Resuscitation Practitioner, Oldham Care Organisation)

Keywords/ phrases:

Resuscitation, intraosseous, intra-osseous, IO, resus, cannulation, emergency

Communication plan:

Competency assessed as part of Advanced Life Support course. Updated equipment checklists added to crash trolleys by resus team.

Document review arrangements:

This document will be reviewed by the author, or a nominated person, at least once every three years or earlier should a change in legislation, best practice or other change in circumstance dictate.

Approval: Approved by CEC DAM (Salford Care Organisation), for use across Northern Care Alliance, chaired by Dr Sara Barton Approved by Resuscitation Committee (Northern Care Alliance), chaired by Dr Michelle MacDougall

Approved on: 14th February 2019 Date amendment approved: 12th February 2020

How approved: Formal Committee decision:




11. Equality Impact Assessment (EqIA) screening tool Legislation requires that our documents consider the potential to affect groups differently, and eliminate or minimise this where possible. This process helps to reduce health inequalities by identifying where steps can be taken to ensure the same access, experience and outcomes are achieved across all groups of people. This may require you to do things differently for some groups to reduce any potential differences.

1a) Have you undertaken any consultation/ involvement with service users, staff or other groups in relation to this document? If yes, specify what.

No

1b) Have any amendments been made as a result? If yes, specify what.

N/A

2) Does this policy have the potential to affect any of the groups listed below differently? Place an X in the appropriate box: Yes, No or Unsure This may be linked to access, how the process/procedure is experienced, and/or intended outcomes. Prompts for consideration are provided, but are not an exhaustive list.

Protected Group Yes No Unsure

Age (e.g. are specific age groups excluded? Would the same process affect

age groups in different ways?) X

Sex (e.g. is gender neutral language used in the way the policy or

information leaflet is written?) X

Race (e.g. any specific needs identified for certain groups such as dress,

diet, individual care needs? Are interpretation and translation services required and do staff know how to book these?)

X

Religion & Belief (e.g. Jehovah Witness stance on blood transfusions;

dietary needs that may conflict with medication offered.) X

Sexual orientation (e.g. is inclusive language used? Are there different

access/prevalence rates?) X

Pregnancy & Maternity (e.g. are procedures suitable for pregnant and/or

breastfeeding women?) X

Marital status/civil partnership (e.g. would there be any difference

because the individual is/is not married/in a civil partnership?) X

Gender Reassignment (e.g. are there particular tests related to gender? Is

confidentiality of the patient or staff member maintained?) X

Human Rights (e.g. does it uphold the principles of Fairness, Respect,

Equality, Dignity and Autonomy?) X

Carers (e.g. is sufficient notice built in so can take time off work to attend

appointment?) X

Socio/economic (e.g. would there be any requirement or expectation that

may not be able to be met by those on low or limited income, such as costs incurred?)

X

Disability (e.g. are information/questionnaires/consent forms available in

different formats upon request? Are waiting areas suitable?) Includes hearing and/or visual impairments, physical disability, neurodevelopmental impairments e.g. autism, mental health conditions, and long term conditions e.g. cancer.

X




Are there any adjustments that need to be made to ensure that people with disabilities have the same access to and outcomes from the service or employment activities as those without disabilities? (e.g. allow extra time for appointments, allow advocates to be

present in the room, having access to visual aids, removing requirement to wait in unsuitable environments, etc.)

X

3) Where you have identified that there are potential differences, what steps have you taken to mitigate these? Nil required.

4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken? Nil required.

Will this policy require a full impact assessment? No

Author: Luke Winterbourne Sign off from Equality Champion: Jules Wall

Date: 03/07/2018 Date: 06/12/2018




12. Appendices

Appendix 1 – Difficult Vascular Algorithm Appendix 2 – Administration of Lidocaine flowchart Appendix 3 – Locations of 2% Lidocaine Appendix 4 – Locations of EZ-IO kits




Appendix 1 Difficult Vascular Algorithm




Appendix 2 Administration of Lidocaine




Appendix 3 Locations of 2% Lidocaine (Salford Royal)




Appendix 4 Locations of EZ-IO kits

If EZ-IO access kit is used, please return it to the ward/unit you took it from. It is the responsibility of the ward where the IO kit is stored to replace the equipment, not the responsibility of the ward that

used the equipment. Theatres, A+E and PANDA also have EZ-IO kits, although it is recommended to get equipment from the

above locations due to ease of access and need for kit frequently in A+E/PANDA/Theatres.

Intraosseous (EZIO) access Kit Locations (Salford Royal NHS)

(Located in the bottom equipment locker of the ward/units cardiac arrest trolley)

Acute Stroke Unit

B4

B6

Emergency Assessment Unit

Haematology Unit

Heart Care Unit

H1 (MHDU)

Critical Care Unit - Pod A and Pod C

L5

http://www.sedationresource.com/display-product/6-601-00/EZIO-2-AD-Ndls




Intraosseous (EZIO) access Kit Locations (Pennine Trusts)

(Located in the bottom equipment locker of the ward/units cardiac arrest trolley)

AMU, CCU, T4

The Royal Oldham Hospital

Ward 8, Ward 20

Fairfield General Hospital

AMU, CCU

North Manchester General

Hospital

Urgent care Centre

Rochdale Infirmary

http://www.sedationresource.com/display-product/6-601-00/EZIO-2-AD-Ndls