In the previous articles, we talked about the indications, contraindications, use, landmarking, insertion and maintenance of the EZ-IO vascular access system. In this final installment, we will cover insertion in the pediatric patient, pain control and removal of the device. As stated earlier, this device like all other medical devices, has limitations. No medical device fits ALL patients and works flawlessly in all situations. The provider is responsible for maintaining competency in insertion and maintenance to ensure proper patient outcomes. The EZ-IO device offers the healthcare provider an additional option for reliable, rapid vascular access in the urgent, emergent or medically necessary situations in patients with difficult vascular access.
Historically, pediatric patients make up a small proportion of most providers’ overall patient contacts. To be presented with a medically unstable pediatric patient that requires immediate vascular access can cause anxiety in even the most experienced providers. While the same equipment is utilized for IO access on the pediatric patient, landmarking must be altered to account for smaller bone structures and differing cortical bone make up. Pediatric bones also tend to be less ossified and more cartilaginous so IO insertion techniques rely on tactile feedback to ensure proper insertion depth. As soon as a lack of resistance is felt during driver operation, the inserter should remove their finger from the driver trigger and stop the insertion regardless of the distance between the patient’s skin and the hub of the needle. A very common pediatric insertion mistake is to not rely on tactile feedback and insert the needle too deeply, resulting in possible puncture of the posterior aspect of the inter medullary canal. Proper insertion landmarking for the proximal tibia is often obtained by measuring 1 cm medially to the tibial tuberosity if it can be palpated. If the tibial tuberosity cannot be reliably located, then the insertion site is 1-2 cm below the patella anteriorly and then approximately 1 cm medially to that site along the flat aspect of the tibial tuberosity. Distal femur insertion is indicated in the pediatric patient only (less than 21 years of age). Prior to landmarking, the lower extremity must be fully extended or outstretched to ensure the knee does not bend during or after insertion. The insertion site is is approximately 1-2 cm proximal or above the top of the patella and approximately 1-2 cm medially to the midline. For larger pediatric patients, distal femur landmarking may involve palpating 3-5 cm above the top of the patella before moving 1-2 cm medially. Proximal humerus landmarking in the young pediatric patient may be difficult due to the fact that young patients often due not present with a prominent, easily palpable greater tubercle. If the greater tubercle can be palpated reliably, then location landmarking and insertion angle will remain the same as in the adult patient. As stated in previous installments, overlying tissue depth will dictate the appropriate needle length and corresponding hub color to be used for insertion.
Unlike peripheral intravenous lines, IO access infusion related pain is something that must be expected. While the inter medullary canal is very vascular, it is also lined with stretch receptors that respond to pressure changes within the cavity. Rapid infusions of fluids or medications can result in varying levels of infusion related pain. While most patients report insertion pain itself to be no worse than an intravenous vascular access attempt, infusion related pain is often directly related to the infusion rate and anatomic insertion site. Most patients report less pain in the proximal humerus over all other insertion sites. This is assuming however that the patient is conscious or aware enough to perceive pain in the first place. The IO infusion related pain management protocol is facility specific and the provider should always refer to their agency’s policies, procedures, protocols or guidelines. Most facilities utilize Epinephrine free, preservative free 2% Lidocaine for infusion related pain. The most common initial dose of Lidocaine is 40 mg directly infused into the IO hub over a full 120 seconds in the adult patient. Pediatric patient dosage is often 0.5 mg/kg up to 40 mg maximum dose. Once the initial Lidocaine dose is given, the infusion should be allowed to remain in the inter medullary canal for 60 seconds and then followed by a rapid infusion of 5-10 ml of sterile saline. A follow up dose of one half of the initial dose may be administered after attaching the extension set if the patient requires it after the rapid flush. It is important to realize that infusion pain management protocol may take up to 4 min to perform so it usually is only utilized in the patient that is hemodynamically stable and requiring analgesia due to infusion related pain complaints. If the IO pain management protocol is ineffective in managing infusion related pain, systemic pain control may be considered.
Removal of the EZ-IO device is fairly straight forward and painless. After removing the EZ-IO securing device (if utilized) and disconnecting the extension set, attach a luer lock syringe to the hub of the IO needle. Rotate the syringe AND the hub of the needle clockwise while pulling straight out and maintaining axial alignment. Try not to rock the needle or the syringe as this may bend the needle and can cause the needle to break. Once the IO needle is removed, place the needle an attached empty syringe in an appropriate sharps container and dress the site as per your agency or institutional protocol. In most patients, post removal site bleeding is minimal and their are no activity restrictions related to the removal procedure. They patient is often advised to follow up if there are any signs or symptoms of infection at the insertion/removal site.
Vascular access options have come a long way in the past 25-50 years. The healthcare provider has more options now than ever before to provide reliable, rapid vascular access regardless of hemodynamic status and vascular anatomy. Utilizing the appropriate device at the appropriate time in the appropriate patient is the challenge that faces many of us. EZ-IO offers you yet another “tool” in your patient care “tool box” to improve patient outcomes and minimize treatment delays. Gone are the days of waiting to perform IO insertion only after all other vascular access options have been exhausted. The EZ-IO device can be the bridge between no vascular access and longer term vascular access devices when the patient presents with difficult vascular access regardless of cause.
