IO Infiltration?

[michael150]

Hey all you experienced medics out there...

Just got off of work in a busy emergency department here in Omaha. At the end of shift we had a code 3 unresponsive party, no gag reflex, with snoring respirations. We opted to intubate but after 2 IV attempts, I placed an IO. She was a bigger lady that ultimately got a central line. I used the yellow 15g larger needle and placed it in her tibial tuberosity with good blood return and easier flushing than I remembered with my previous insertions. She didn’t move on the flush at all. MD ordered the administration of RSI meds and she stopped breathing on her own, so I am positive the meds got in. Started pressure bagging an NS bolus and about 15min later, the area began swelling and leaking out from around the needle... Again, I got blood return and I’m positive that I was in. The IO did NOT get dislodged because it was still flush with her skin. Charge RN whom I trust with her many years of ICU and ER experience says she thinks the IO infiltrates because it was no longer easy to push but we still got blood return. My question to you guys is this: Has anyone ever had an IO “infiltrate”? I am a little confused on this happens because it’s bone? It’s not like the vein blew but if I’m in the medullary cavity, how does that happen? Anyone?...

 

[chrls]

I’m sure somebody will have a better answer but after going to a few cadaver labs where the arrow easy IO has been demo’d I can think of a few possibilities.

First thing is the yellow needle is generally considered for use in patients with extra tissue to go through before reaching the bone/cavity. The manufacturer actually intends the yellow for humeral head placement. There usually isn’t THAT much excess tissue to get through over the tibial site that the yellow is required. You also don’t necessarily need to burry the needle to the hub. Only apply gentle pressure to the driver and let the RPM drill through the bone stopping when you feel a drop in resistance. Having visible needle between the site and the hub isn’t a bad thing.

In short, you might have gone through the bone and out the back.

Another option is during placement the needle wobbled around boring out a larger than necessary hole in the bone creating an area around the needle for fluid to escape the cavity.

 

[michael150]

I’m sure somebody will have a better answer but after going to a few cadaver labs where the arrow easy IO has been demo’d I can think of a few possibilities.

First thing is the yellow needle is generally considered for use in patients with extra tissue to go through before reaching the bone/cavity. The manufacturer actually intends the yellow for humeral head placement. There usually isn’t THAT much excess tissue to get through over the tibial site that the yellow is required. You also don’t necessarily need to burry the needle to the hub. Only apply gentle pressure to the driver and let the RPM drill through the bone stopping when you feel a drop in resistance. Having visible needle between the site and the hub isn’t a bad thing.

In short, you might have gone through the bone and out the back.

Another option is during placement the needle wobbled around boring out a larger than necessary hole in the bone creating an area around the needle for fluid to escape the cavity.

I thought about going out the back after the initial placement but if that were the case, I wouldn’t have gotten good blood and marrow return. Additionally, the RSI medications would not have worked because the needle would have been outside of the medullary cavity or in the periosteum. Am I correct in thinking that? I’ll probably use a smaller needle next time because if this incident and the loss of access but I’m just confused.

 

[NPO]

First thing is the yellow needle is generally considered for use in patients with extra tissue to go through before reaching the bone/cavity. The manufacturer actually intends the yellow for humeral head placement. There usually isn’t THAT much excess tissue to get through over the tibial site that the yellow is required.

Correction. They recommend the yellow needle, and they recommend humoral head. But they don't recommend only use the yellow for the humoral head.

They recommend the yellow needle because you don't have to burry it, you can stop when ever it's in but the smaller blue needle can only go so far. In fact the yellow one is yellow because fat tissue is yellow. True story.

There is very little fat to go through at the humoral site, which is one reason they recommend it. The tibial site was actually only approved because it was easier to approve. The doctor who invented it tells everyone not to use it because humoral is better.

One possibility as to why it infiltrated is a sloppy hole. If the needle moved around it can make the hole bigger. If they're excessively fat, the fat can pull the needle out (another argument for humoral).

 

[chrls]

I thought about going out the back after the initial placement but if that were the case, I wouldn’t have gotten good blood and marrow return. Additionally, the RSI medications would not have worked because the needle would have been outside of the medullary cavity or in the periosteum. Am I correct in thinking that? I’ll probably use a smaller needle next time because if this incident and the loss of access but I’m just confused.

Both of us think a sloppy hole could be the culprit.

I was just giving options earlier with the over penetration example. You’d know real quick if you went through. Like you said, medications wouldn’t have worked or would have been greatly delayed in absorption and/or potency. Also, if it really was 15 minutes with a pressure bag and the volume remaining in the bag was decreasing, the surrounding area would be noticeably swollen.

 

[silver]

How was the insertion itself? Did you feel loss of resistance? Did you advance 1-2cm (max) after LOR to insure intramedullary? Did it go in perfectly perpendicular to bone?

I think you are pretty on point with your thought process regarding what the possibilities were. Given that its a beveled there is always the possibility it can be partially out, but still able to flush for some time. The same holds true if it was advanced beyond 1-2cm after LOR and just hubbed right away. Additionally, if its not 100% perpendicular your tract through bone may be wider than the catheter.

Lastly, I know this is hard to follow up, but was there difficulty in removing it? I've seen more than 1 fairly bent catheter.

 

[Peak]

I would also consider the possibility of fracture. We see fractures in neonates and heme/onc kids pretty often from outside EDs, and is definitely possible in adults as well.

Keep in mind that even a small fracture, having leaks around the insertion site of the bone, having gone through the back side and withdrawing, et cetera will likely still withdraw and flush, and with a slow push med would likely still deliver medications. In this situation if you add pressure over a longer period of time that that small leak builds up and becomes noticeable.

I wouldn't worry about it too much, I've seen so many IO insertion complications that they are not out of the ordinary. I've seen complications from rural low volume EMTs through flight nurses and medics with decades of experience. There are many reasons why we yank those things out as soon as we place a line or have reliable adequate IV access.

IOs certainly have a place in emergent access, but they aren't the golden goose that some people make them out to be. I've only ever placed one, and it was on a code in an adult ICU who had a quad lumen central line and needed to be mass transfused.

 

[E tank]

if it works, nothing else matters.

 

[NomadicMedic]

We place a tibial IO in almost every code and >95% of them have zero issue. Most of the problems I've seen are from using the blue needle in a patient with excessive adipose tissue, going straight through with the yellow needle or wobbling the driver when placing the needle set resulting in an oval hole.

I think the NIO will be a decent replacement for the overpriced EZIO needle sets and our aging drivers.

 

[RocketMedic]

+1 on the NIO.