The Emergency Nurses Association and ACEP both have positions that support the use of intraosseous (IO) vascular access to include insertion by nurses. Yet IO remains an underutilized technique in most emergency departments. Nurses say that doctors are unfamiliar, uncomfortable, and resistant to using IO. Doctors say that nurses are unfamiliar, uncomfortable and resistant to using IO. The time is now for us to stop pointing fingers at each other and move toward overcoming the barriers to IO that exist in our EDs.

It appears the barriers to IO are rooted in misunderstanding, unfamiliarity, misplaced fears, and our natural desire to cling to the comfort we find with the technologies of the past. We accept common myths as fact and thus rationalize our opposition to IO. The truth is that inserting an IO needle is safe, fast, effective, easy, and no more painful than insertion of a peripheral intravenous (IV) catheter or other common ED procedures.

The technique of IO insertion can be easily and quickly taught, even to novices. In one study, medical students unfamiliar with the technique were instructed and became comfortable and competent within hours. It is not uncommon for paramedics and nurses to insert IOs, unlike central lines that are usually inserted by a physician, nurse practitioner, or physician assistant.

Serious complications are virtually nil. Osteomyelitis from an IO approaches one case per million insertions. Extravasation is the most common problem and affects up to 5% but is usually of no clinical concern. Compartment syndrome is a more serious complication from unrecognized extravasation yet remains rare and is usually limited to small children and due to inadequate monitoring of the site.

Flow rates are generally more than adequate. Research has shown the average flow rate for the proximal humerus to be 5 liters per hour and as high as 9 liters per hour when infused under pressure at 300 mm Hg. Other studies have shown IO access to be suitable for contrast administration for CT scans.

The medicines that can be given IO are virtually no different than those that can be given via any peripheral intravenous (IV) line. Numerous studies have shown pharmacologic equivalence of drugs administered IO and IV.

Intraosseous access costs less than a central line. Central lines require ultrasound guidance or X-ray confirmation and full sterile technique to avoid the mortality and high expense in both dollars and pain and suffering associated with central line infections. These precautions add hundreds of dollars to the cost of central vascular access. The cost of an IO is approximately what would be spent on three attempts at inserting a peripheral line.

With benefits that far outweigh the disadvantages, we wonder why resistance to IO persists. We wonder why we don’t have the courage to step out of our comfort zones? We wonder how we can continue to justify not using IO when indicated. Clearly our professional ethics demand that we adjust to new technologies despite our comfort with the old. Our patients deserve the best from us, and we can and should deliver it to them.

We call upon emergency nurses and physicians alike to work together to implement IO as a standard method of vascular access in EDs across the country. We call upon them to dispel the myths of IO and promulgate the truths. We call upon them to educate and teach their peers. We call upon them to become the local champions and lead their facilities toward the improved safety and outcomes that IO offers. We call upon the Deans of Nursing and Medical Schools to include IO in the curricula for their students. And we call upon the residency program directors in emergency medicine, pediatrics, internal medicine, family practice, and other disciplines to include IO in the training of their residents.

Our patients deserve the benefits IO access can deliver, and we owe it to them to become knowledgeable, familiar, and competent with the technique. Let’s agree to agree for the benefit of our patients and start down that path together. Let’s start today.

References

• Abe K, Blum G, Yamamoto L. Intraosseous is Faster and Easier than Umbilical Venous Catheterization in Newborn Emergency Vascular Access Models. Am J Emerg Med 2000; 18: 126-129.
• Alternative Methods to Vascular Access in the Emergency Department. ACEP Clinical Policy; June 2011.
• Emergency Nursing Resource: Difficult Intravenous Access. ENA; December 2012
• Eng M, Ong H, Chan Y, Oh J, Ngo A. An Observational Prospective Study Comparing Tibial and Humeral Intraosseous Access Using the EZ-IO. Am J Emerg Med 2009; 27: 8 – 15.
• Levitan RM, Bortle CD, Snyder TA, et al. Use of a battery-operated needle driver for intraosseous access by novice users: Skill acquisition with cadavers. Ann Emerg Med. 2009;54:692-694.
• Ong MEH, Chan YH, Oh JJ, Ngo AS-Y. An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO. Amer J Emerg Med. 2009;27:8-15.
• Rogers J. Safety of Intraosseous Vascular Access in the 21st Century. Presentation to the 2012 World Congress of Vascular Access.
• Santolucito J. A retrospective evaluation of the timeliness of physician initiated PICC referrals: a continuous quality assurance/performance improvement study. J Vasc Access Devic. 2001;6:20-26.
• Stein J, George B, River G, et al. Ultrasonograhically guided peripheral intravenous cannulation in emergency department patients with difficult intravenous access: a randomized trial. Ann Emerg Med. 2009;54:33-40.
• Stouffer JA, Jui J, Acebo J, Hawks R. The Portland IO experience: results of an adult intraosseous infusion protocol. JEMS. 2007;32:s27-8.
• Vidacare Corporation. Hospital Value Analysis. 2012
• Vizcarra C, Clum S. Intraosseous Route as Alternative Access for Infusion Therapy. Journal of Infusion Nursing 2012; 33:162-174.
• Von Hoff D, Kuhn J, Burris H, Miller L. Does Intraosseous Equal Intravenous? A Pharmacokinetic Study. Am J Em Med 2008; 26: 31-8. Research sponsored by Vidacare.

*Consultant for Vidacare Corporation