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.
Explore This IssueACEP News: Vol 32 – No 11 – November 2013
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.