Download Use of Intraosseous Vascular Access in the Adult Population

Running head: INTRAOSSEOUS VASCULAR ACCESS
Use of Intraosseous Vascular Access in the Adult Population
Stacey Swartzendruber
Ferris State University
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Abstract
The need for intraosseous (IO) devices to be stocked on crash carts throughout the hospital has
been of recent debate between the emergency room staff and the general medical and surgical
staff. Concerns have been identified and research pertaining to those concerns is described
below and relate to the amount of time it takes to place an IO. Also discussed is the comparison
of the pharmacokinetics between morphine sulfate administered intravenously and
intraosseously.
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Intraosseous Vascular Access in the Adult Population
The use of intraosseous vascular access in the adult population has been of recent
discussion during meetings at the hospital where I work. Currently, the emergency department
will place an intraosseous cannula in an adult patient who is in critical condition where
peripheral intravenous access is inaccessible at that time. These devices are not stocked on crash
carts used for emergent situations throughout the hospital. During an adult emergency, both the
emergency room physician and one emergency room nurse respond to the emergency. They use
the crash cart from the specific floor to obtain supplies and medication that will be used for that
event. In the event that the patient does not have intravenous access, staff relies on the stock of
peripheral intravenous catheters and central venous catheters within their crash carts to obtain
vascular access with.
Requests from the emergency department staff to stock intraosseous needles and insertion
devices on crash carts throughout the hospital have been met with some resistance from the
general medical and surgical staff unfamiliar with this technique. Reasons against stocking
hospital-wide have varied. Some of the most frequent comments I have heard while speaking to
people about this topic were:

A central line would be more beneficial to the patient because labs could be taken
from the patient once resuscitation is over and invasive monitoring could be
performed through a central line.

The time it takes for medication to reach circulation must be slower with use of
intraosseous needles versus a central line.
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
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Drilling into the bone of a patient must be difficult and too technical for a nurse to
be performing.
While concerns from the staff may at first seem reasonable, research is proving
otherwise. Below are three research articles pertaining to the use of intraosseous insertion for
critical patients in need of vascular access. Each article addresses the common questions and
concerns staff currently has.
Research Article One
Research Findings
The first research article compares two common approaches to obtaining vascular access
in a patient where peripheral intravenous (IV) cannulation is unattainable during critical medical
conditions (Leidel et al, 2009). The two approaches are central venous catheterization (CVC) and
intraosseous vascular access (IO). The study involved patients 18 and older who were seen at a
level 1 trauma center, lacking IV access upon arrival (Leidel et al, 2009). The trauma team
attempted peripheral IV access three times before proceeding with the study. After three
unsuccessful IV attempts, an anesthesiologist began placement of a CVC at the same time a
surgeon placed an IO (Leidel et al, 2009). The time it took to perform each technique (including
time preparing for the procedure), the ability to properly place the devices on the first attempt, as
well as the total number of attempts it took to properly place the devices were recorded (Leidel et
al, 2009).
There were a total of ten patients that were involved in this study (Leidel et al, 2009).
The results were as follows: the success rate for IO was 90% compared to CVC (60%) on first
attempt. Time placement was quicker for IO placement than for CVC placement (2.3 minutes
versus 9.9 minutes, respectively) (Leidel et al, 2009).
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Critique of Research
A limitation of this study was the population size used (ten patients). Even though results
were consistent, it would be beneficial to see this study applied toward a larger patient number.
Implications for Practice
This research validates the use of intraosseous cannulation when peripheral intravenous
access is unattainable. In regards to my own practice, we have been using IO as a first route of
vascular access in critically ill patients who lack IV access. After resuscitation or stabilization,
the patient then receives a central venous catheter under a more controlled setting. This study
reinforces that this nursing task is appropriate in these situations. This study also enables me to
stress the importance of the need for IO availability on crash carts, as obtaining IV access during
cardiac arrest can be difficult and time consuming. The IO can provide that vascular access
quicker than a CVC could (Leidel et al, 2009).
Research Article Two
The next research article focused on a specific brand of intraosseous insertion devices,
the EZ-IO which is one of the two that is carried in the department I work in (Su Yin, Oh, Chen,
Yong, & Ong, 2009). Again…as above..regarding title and authors
Research Findings
This study was performed to determine whether IO cannulation was an “alternative to
vascular access in the emergency department” (Su Yin, Oh, Chen, Yong, & Ong, 2009, pp. 155).
The study lasted from March of 2006 until July of 2007 and studied the use of IO access in 24
patients (Su Yin, Oh, Chen, Yong, & Ong, 2009). The patient population was patients ages 16
and older who came to the emergency department critically injured or ill and did not have
achievable peripheral IV access (Su Yin, Oh, Chen, Yong, & Ong, 2009). Other criteria were
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present that qualified them as a critical patient (due to mental status, respiratory status, blood
pressure problems, or presence of cardiac arrest) (Su Yin, Oh, Chen, Yong, & Ong, 2009).
Success rates and number of attempts were recorded, as well as site placement. Flow rates of the
IO fluids were monitored and recorded, as well as any complications encountered (Su Yin, Oh,
Chen, Yong, & Ong, 2009). The findings indicate that Io use by way of EZ-IO is an appropriate
alternative to IV access for patient resuscitation, especially when pressure bags were used to
assist in faster fluid administration (Su Yin, Oh, Chen, Yong, & Ong, 2009).
Critique of Research
This research also has a limitation of the number of patients. A larger patient population
would be useful to ensure consistent results. This research was done at a large emergency
department and its authors work within that department. A special note was included, stating,
“no cast sponsorship was used for this study” although EZ-IOs were provided by the maker of
them (Su Yin, Oh, Chen, Yong, & Ong, 2009, pp. 159).
Implications for Practice
This research article once again supports the use of IO access when IV access is
unattainable during the immediate resuscitation period. It applies toward my clinical practice
because we use the EZ-IO as one of our IO placement devices.
Research Article Three
The last article looks at another question raised by other staff members at my facility: is
the administration of medications through an IO the same as through an IV? (Von Hoff, Kuhn,
Burris, & Miller, 2008). As above
Research Findings
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This article describes research that aimed to compare the pharmacokinetics of IO and IV
medication. This study used morphine sulfate as the drug for comparison (Von Hoff, Kuhn,
Burris, & Miller, 2008). Cancer patients at eight clinical sites who were not able to maintain IV
access were chosen as the patient population. They had implanted IO devices placed as well as
an IV. A dose of morphine sulfate was given to the patient via one site (either IO or IV) and
blood draws were obtained prior to administration, and at defined times periods postadministration. The patient then received the same dose of morphine sulfate 24 hours later via
the other vascular access route (if they first received it through IO, they would then receive it IV
24 hours later), and again had blood draws in the same manner (Von Hoff, Kuhn, Burris, &
Miller, 2008).
Results showed “no significant differences between the IO and IV route on plasma
morphine concentration vs. sampling data” (Von Hoff, D., et al, 2008, pp. 35) . The study also
states “ the IO and IV delivery results for morphine sulfate were essentially equivalent” (Von
Hoff, D., et al, 2008, pp. 35).
Critique of Research
This research was done at more than one clinical site across the United States (Von Hoff,
D., et al, 2008 ). The Institutional Review Boards of each institution approved this study (Von
Hoff, D., et al, 2008). While the results for morphine sulfate showed that both routes were
equivalent (Von Hoff, D., et al, 2008), it does not mean that it would be the same for every drug.
Implications for Practice
This research does not change our practice in the emergency department, but again allows
me to provide other staff members, who are showing some resistance to the efficacy of this route
of medication administration, information supporting its use.
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Critical Reflection
Each of these research articles relate to a nursing theory by Afaf Ibrahim Meleis: the
transition theory (Alligood & Tomey, 2010). Again..this should read, Alligood & Tomey,
2010….This nursing theory describes the levels of transition that a person goes through:
awareness, engagement, change and difference, time span, and critical points and events
(Alligood & Tomey, 2010). Using this theory, it is not a patient that is going through the
transition, but it is the hospital and staff that are going through transition. Awareness of a
possible need for change in routine has been addressed. Staff has become engaged in the
discussion surrounding the use of intraosseous needles and why it is necessary to keep them
stocked on the crash carts for use during an emergency. Changes have been identified, and it is
in this part of transition where the difficulty to move forward lies. It would be a change in
nursing practice for some of the floor nurses to become familiar with insertion and maintenance
of an intraosseous device. Competencies would need to be developed and education
implemented. The possibility of changes in cost due to stocking of an infrequently used supply
is present.
The remaining stages of transition in regards to this nursing topic will not be completed
until a decision has been made whether to accept this change or stay with current practice. If
there is a positive movement forward, a time span for completion of this transition to the use of
intraosseous needles throughout the hospital needs to be identified. Critical points would be
when the staff has begun using this device and feedback regarding it occurs. The staff may
participate more in the delivery of this care and begin teaching it to new employees and
recognize the positive change that has occurred.
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While it may take a while for staff to agree that there is a need to stock intraosseous
insertion devices on crash carts throughout the hospital, I strongly feel that this discussion should
continue. While I can understand some of the concerns of other staff members, I feel that a lack
of education regarding the benefits of these devices is the biggest barrier to moving forward with
this change. The research is proving that it is beneficial to the patient and is less time consuming
to use intraosseous devices (Leidel et al, 2009). I will continue to research this topic and provide
evidence that these devices are truly a benefit to the patient, and are worth stocking throughout
the hospital.
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References
Alligood, M., & Tomey, A. (2010). Afaf Ibrahim Meleis: Transition theory. Nursing Theorists
and Their Work (pp. 416-433). Maryland Heights, MO: Elsevier.
Leidel, B., Kirchhoff, C., Bogner, V., Stegmaier, J., Mutschler, W., Kanz, K., & Braunstein, V.
(2009). Is the intraosseous access route fast and efficacious compared to conventional
central venous catheterization in adult patients under resuscitation in the emergency
department? A prospective observational pilot study. Patient Safety in Surgery, 3, 24.
doi:10.1186/1754-9493-3-24
Von Hoff, D., Kuhn, J., Burris, H.,& Miller, L. (2008). Does intraosseous equal intravenous? A
pharmacokinetic study. American Journal of Emergency Medicine, 26, 31-38.
doi:10.1016/j.ajem.2007.03.024
Su Yin, A., Oh, J., Chen, Y., Yong, D.,& Ong, M. (2009). Intraosseous vascular access in
adults using the EZ-IO in an emergency department. International Journal of Emergency
Medicine, 2, 155-160. doi 10.1007/s12245-009-0116-9