Current Status: Draft PolicyStat ID: EZIO

DRAFT

Current Status: Draft PolicyStat ID: 1547809

Originated: N/A

Reviewed: N/A

Last Revised Or Downloaded: N/A

Expiration: N/A

Document Area: Nursing

EZIO

POLICY STATEMENT:

BLOOD BORNE PATHOGEN

EQUIPMENT:

• NEEDLE SET SELECTION:

◦ Select EZ-IO®_{Needle Set based on patient weight, anatomy and clinical judgment. The EZ-IO}® Catheter is marked with a black line 5 mm proximal to the hub. Prior to drilling, with the EZ-IO® Needle Set inserted through the soft tissue and the needle tip touching bone, adequate needle length is determined by the ability to see the 5 mm black line above the skin.

◦ EZ-IO®_{45 mm Needle Set (yellow hub) should be considered for proximal humerus insertion in} patients 40 kg and greater and patients with excessive tissue over any insertion site

◦ EZ-IO®_{25 mm Needle Set (blue hub) should be considered for patients 3 kg and greater} ◦ EZ-IO®_{15 mm Needle Set (pink hub) should be considered for patients approximately 3-39 kg} In the event that peripheral venous access is unobtainable, guidelines have been established for the

intraosseous (IO) access technique to be used. IO insertion, maintenance and removal may only be completed by a physician, qualified registered nurse or paramedic who have been appropriately trained for the procedure.

EXPOSURE CATEGORY: I (Involves exposure to blood, body fluids, or tissues) FUNCTION: Care of Patients

DRAFT

• EZ-Stabilizer®_Dressing

• Non-sterile gloves

• Luer lock syringe with intravenous (IV) Normal Saline flush (5-10 mL for adults, 2-5 mL for infant/child) • Sharps container or NeedleVISE 1 port sharps block

DRAFT

ADDITIONAL EQUIPMENT/SUPPLIES IF INDICATED/

ORDERED:

• 2% preservative-free & epinephrine-free lidocaine (intravenous lidocaine) • Intravenous fluid

• Infusion pump or pressure bag, IV tubing • Supplies for lab samples

POINTS OF EMPHASIS:

• INDICATIONS

◦ For emergent and nonemergent IO access when IV access cannot otherwise be obtained and when the patient might be at risk of increased morbidity or even mortality if access is not obtained.

◦ Any medication that can be safely given intravenously can be given IO with the exception of chemotherapy, total parental nutrition (TPN) and prolonged or repeat doses of hypertonic saline. ◦ For adult, pediatric and infant patient access for up to 24 hours.

• CONTRAINDICATIONS

◦ Fracture in the same extremity of the targeted bone

◦ Previous, significant orthopedic procedures at insertion site (e.g. prosthetic limb or joint) ◦ Previous failed intraosseous access within 24 hours in the targeted bone

◦ Infection at the insertion site or within the targeted bone ◦ Inability to locate the landmarks

• WHAT TO MONITOR AND DOCUMENT: ◦ The needle is secure, intact and patent

◦ The EZ-Stabilizer®_{Dressing and connections are secure} ◦ Need for additional pain medication

◦ EZ-IO®_{band is placed on patient} ◦ Monitor for complications including:

▪ Clotting of bone marrow resulting in loss of revascular access ▪ Fracture of the bone

▪ Damage to the epiphysis ▪ Fat embolism

▪ Osteomyelitis

▪ Signs of extravasation (fluid infiltration of subcutaneous tissue/subperiosteal area) ▪ Signs of compartment syndrome

▪ Signs of infection

PROCEDURE:

• When possible, explain procedure to patient/family • Obtain assistance as needed

• Wash hands

• INSERTION SITE IDENTIFICATION:

◦ IO SITES (NOTE: Do not insert in sternum site) ▪ Adults

▪ Proximal humerus ▪ Proximal tibia

DRAFT

◦ 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:

• INSERTION SITE IDENTIFICATION:

◦ Proximal Humerus (Adult/Child/Infant) (see attachment for additional illustrations)

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

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

4. 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

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

6. Palpate deeply up the humerus to the surgical neck

7. This may feel like a golf ball on a tee – the spot where the "ball" meets the "tee" is the surgical neck

8. The insertion site is 1 to 2 cm above the surgical neck, on the most prominent aspect of the greater tubercle

• ADULT INSERTION SITE IDENTIFICATION: ◦ Proximal Tibia (Adult)

1. Extend the leg.

2. Insertion site is approximately 2 cm medial to the tibial tuberosity. This is approximately 3 cm below the patella and approximately 2 cm medial, along the flat aspect of the tibia.

DRAFT

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 center aspect of the bone.

• INFANT/CHILD INSERTION SITE IDENTIFICATION: ◦ 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. This is just below the patella

DRAFT

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 center aspect of the bone.

◦ 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.

DRAFT

◦ Use a clean, "no touch" technique, maintaining asepsis ◦ Prepare supplies

◦ Prepare the site by using chloroprep; stabilize the extremity ◦ Remove the needle set cap

◦ Proximal Humerus – Adult/Child/Infant

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 touches 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

• ADULT INSERTION TECHNIQUE: ◦ Tibia - Adult

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

2. Push the needle set tip through the skin until the tip touches 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

DRAFT

◦ Femur and Tibia – Infant/Child

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

b. Push the needle set tip through the skin until the tip touches the bone

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

set length

c. 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:

A. Hold the needle 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.

B. Place the EZ-Stabilizer®_{Dressing over the hub.}

C. Attach a primed extension set to the catheter hub and firmly secure by twisting clockwise. D. Pull the tabs off the dressing to expose the adhesive and apply to the skin

E. 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.

F. Proceed with technique below, based on situation:

1. ADULT - RESPONSIVE TO PAIN – RECOMMENDED ANESTHETIC- MUST OBTAIN

PHYSICIAN ORDER

Observe recommended cautions/contraindications to using 2% preservative free and epinephrine-free lidocaine (intravenous Lidocaine)

a. Prime extension set with lidocaine

(Note: Priming volume of the EZ-Connect® Extension Set is approximately 1 mL). b. Slowly infuse lidocaine 40 mg IO over two minutes

c. Allow lidocaine to dwell in IO space one minute d. Flush with 5 to 10 mL of normal saline

e. Slowly administer an additional 20 mg of lidocaine IO over 60 seconds

▪ Repeat PRN; consider systemic pain control for patients not responding to IO lidocaine

2. ADULT - UNRESPONSIVE TO PAIN a. Prime extension set with normal saline

DRAFT

3. INFANT/CHILD - RESPONSIVE TO PAIN – RECOMMENDED ANESTHETIC- MUST OBTAIN

PHYSICIAN ORDER

Observe recommended cautions/contraindications to using 2% preservative free and epinephrine-free lidocaine (intravenous Lidocaine)

a. Prime extension set with lidocaine. (Note: Priming volume of the EZ-Connect®_Extension Set is approximately 1 mL).

b. For small doses of lidocaine, consider administering by carefully attaching syringe directly to needle hub (prime extension set with normal saline)

c. Slowly infuse 0.5 mg/kg, not to exceed 40 mg Lidocaine over two minutes d. Allow lidocaine to dwell in IO space for one minute

e. Flush with 2-5 mL of normal saline

f. Slowly administer subsequent lidocaine (half the initial dose) IO over one minute ▪ Repeat PRN; consider systemic pain control for patients not responding to IO

Lidocaine

4. INFANT/CHILD - UNRESPONSIVE TO PAIN a. Prime extension set with normal saline

b. Flush the IO catheter with 2-5 mL of normal saline

If patient develops signs indicating responsiveness to pain, refer to infant/child recommended anesthetic technique.

G. Connect fluids if ordered and pressurize up to 300 mmHg for maximum flow H. Verify placement/patency prior to all infusions.

I. 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. J. Document date and time on wristband and place on patient

• REMOVAL TECHNIQUE:

A. Remove extension set and dressing.

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

C. Maintaining axial alignment, twist clockwise and pull straight out. Do not rock the syringe. D. Dispose of catheter with syringe attached into sharps container.

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

DOCUMENTATION:

1. The patient's vital signs and response to the procedure. 2. The time and site of IO placement.

DRAFT

5. The physician, paramedic or RN performing the procedure.

6. The time and condition of the IO site when the needle was removed.

REFERENCES:

• American Heart Association (2010). American Heart Association Guidelines for Cardiopulmonary

Resuscitation and Emergency Cardiovascular Care. Part 7.2: Management of Cardiac Arrest. Circulation, 112(suppl): IV-58-IV-66.

• Vizcarra, Cora MBA, RN, CRNI(R); Clum, Susan, BSN, CRNI(R) (2010). Intraosseous Route as Alternative Access for Infusion Therapy. Journal of Infusion Nursing, 33(3), 162-174.

• Infusion Nurses Society (2009). The Role of the Registered Nurse in the Insertion of Intraosseous Access Devices. Journal of Infusion Nursing, 32(4), 187-188.

• Phillips, Lynn MSN, RN, CRNI(R), et al (2010). Recommendations for the Use of Intraosseous Vascular Access for Emergent and Nonemergent Situations in Various Health Care Settings: A Consensus Paper. Journal of Infusion Nursing, 33(6), 346-351.

• Von Hoff DD, Kuhn JG, Burris HA, Miller LJ. Does intraosseous equal intravenous? A pharmacokinetic study. Amer J Emerg Med 2008;26:31-8. 2

• Hoskins SL, Kramer GC, Stephens CT, Zachariah BS. Efficacy of epinephrine delivery via the intraosseous humeral head route during CPR. Circulation 2006;114:II_1204.VS 3

• Hoskins S, Nascimento P, Espana J, Kramer G. Pharmacokinetics of intraosseous drug delivery during CPR. Shock 2005;23:35.VS 4

• Hoskins SL, Nascimento P Jr., Lima RM, Espana-Tenorio, JM, Kramer GC. Pharmacokinetics of intraosseous and central venous drug delivery during cardiopulmonary resuscitation. Resuscitation 2012;83(1):107-12.VS

• Hixson R. Intraosseous administration of preservative-free lidocaine. http://www.vidacare.com/files/ Hixson- Lidocaine-%20032012.pdf. Accessed November 22, 2013.

All revision dates:

Attachments:

