EZ-IO® INTRAOSSEOUS INFUSION

Inclusion criteria: This procedure description is intended to supplement the standard, symptom-based UTSW/BioTel EMS Treatment Guidelines.  The Vidacare® EZ-IO® may be attempted on any critically ill patient weighing at least 3 kg, when peripheral intravenous (IV) access is unavailable or unsuccessful or may result in excessive treatment delay. The proximal tibia is the standard insertion site; the proximal humerus or other sites may be used by providers trained to use these insertion sites.

1. Contraindications:
   • Fracture of the selected bone
   • Infection at the insertion site
   • Excessive tissue at the insertion site
   • Inability to locate anatomic landmarks
   • Vascular compromise of the extremity
   • IO insertion or orthopedic procedure within prior 24 hours at the same site
   • Hypertonic (3% or greater) saline infusion
2. Indications for critical illness/injury requiring fluid resuscitation and/or medications:
   • After 1 or 2 peripheral IV attempts or 90 seconds:
   • Any critical illness or injury
     
     
   • Consideration for insertion PRIOR to IV attempts:
     • Cardiac arrest
     • Profound hypovolemia or shock, with altered mental status
3. Equipment:

• Vidacare® EZ-IO® driver
• Vidacare® EZ-IO® needle set correct for age***
• Iodine (or alcohol) swab
• 1 or 2 10 mL syringes of Normal Saline
• Standard IV infusion set (any age patient) – flushed and primed
• Pressure bag
• 1 Liter bag of Normal Saline
• 3-way stopcock, if available (pediatric patient)
• Primed IV extension set (or EZ-Connect®)
• Vidacare® EZ-IO® Stabilizer or gauze/tape
• 1 pre-filled syringe of 2% lidocaine (optional
  

4. Procedure:
   • Wear approved BSI protective gear and garments
   • Locate and cleanse the insertion site using aseptic technique
   • Prepare the driver and needle set
   • Stabilize the limb: use towels, blankets, bags of normal saline or other items, NOT a provider’s hand(s)
   • Insert the needle set
   • Remove the driver
   • Remove the stylet from the catheter
   • Confirm placement and attach extension tubing or EZ-IO® Connect, if used
   • Consider administration of 40 mg (2 mL) of 2% lidocaine in the adult, conscious patient; wait 15 seconds
     • For conscious, pediatric patients sensitive to pain, contact BioTel for lidocaine dosing
   • IMMEDIATELY flush with at least 10 mL of Normal Saline – “No Flush = No Flow”
   • Connect IV infusion set and pressure bag
   • Administer fluid, adjusting flow rate, as needed
   • Secure the tubing and catheter using EZ-IO® stabilizer or gauze/tape
     • Provide tubing slack to prevent dislodgement with patient movement
     • Avoid excessive or circumferential tape or gauze (risk of infiltration/compartment syndrome)
   • Document procedure details in ePCR
   • Monitor insertion site frequently for dislodgement, leak/extravasation, infiltration/compartment syndrome
5. Considerations:
   • Flow rates:
     • Due to intraosseous space anatomy, fluid flow rates will be slower than those achieved through a peripheral IV catheter.
     • Regular IV infusion sets must be used, regardless of patient age (no micro-drip set!)
     • IO needle must be flushed with 10 mL of Normal Saline immediately after insertion to prevent clotting and obstruction.
     • A pressure bag will be needed for continuous infusion.
     • Use of a 3-way stopcock is preferred for medication administration in pediatric patients.
     • Excessive tape, gauze or other dressings can hinder fluid flow, lead to tissue infiltration, and cause limb-threatening compartment syndrome
   • Pain:
     • EZ-IO® insertion in conscious patients causes transient, mild-to-moderate discomfort that is typically no more painful than insertion of a large-bore, peripheral IV.
     • Intraosseous infusion can be painful in conscious patients.
     • In the conscious, adult patient, slow infusion of 2 mL (40 mg) of 2% cardiac lidocaine through the needle hub, followed by a 15-second pause before the Normal Saline flush can reduce that pain:
       • IMPORTANT NOTE: Avoid excessive delay after lidocaine infusion – flush immediately with 10 mL Normal Saline to avoid clotting of the IO catheter.
     • For conscious, pediatric patients sensitive to pain, contact BioTel for lidocaine dosing.
6. Possible Complications:
   • Extravasation
   • Dislodgement
   • Compartment Syndrome
   • Fracture
   • Pain
   • Reduced flow
   • Infection
     
7. Removal:
   • The EZ-IO® catheter should be removed within 24 hours of insertion
   • Removal instructions:
     • Stabilize the extremity
     • Connect a sterile, Luer-Lock syringe to the catheter hub
     • Rotate the catheter clockwise, while gently pulling straight back
       • Do NOT rock or bend the catheter during removal
       • Rocking or bending the catheter with a syringe may cause the catheter to separate from the hub
     • Immediately after removal, place the catheter in an appropriate biohazard container
     • Apply a sterile bandage to the insertion site

***EZ-IO® Needle Sizes (Note: all needles are 15 g. - only the length differs among sizes):