Rebecca Engelman, a critical care paramedic and soon to be PA, sent the great tips below on how to secure an IO in a peds patient. She should know because on the equipment securing hierarchy, methods that work in the filed are tops. It goes: things that work in the OR to things that work in the ICU to things that work in the ED and ends with things that work in the eight floor walk-up apartment building or a transport chopper.
How to Place an IO
I'm a critical care paramedic and up until very recently I spend 95% of my time working in pediatric critical care transport.
Tibial IO in small peds (<10kg) can be tricky if you don't do a lot of them. When everyone learned to insert EZIOs in adults, they were probably taught to drill until they felt a ‘pop', then stop…then promptly forgot this direction and drilled until the hub of the catheter was resting on tissue. In adults, this usually doesn't lead to problems due to the size of the medullary space. In small pediatric patients however, sinking the IO to the hub will result in the needle passing THROUGH the tibia. If this is not recognized upon insertion or upon fluid administration it can lead to the complications mentioned by others above.
Everything that I'm about to say is purely my opinion based on my experiences:
– Let someone who knows what they are doing put the EZIO in. We used to have a lot of problems with IO (recognized) failure until we stopped letting residents put them in and made it an attending and critical care paramedic only skill. (Some of our attendings didn't even really belong on that list, that was just a politics thing.) We rarely had any issues after that. The point is, just like airway, if you don't do it a lot in small kids, you probably aren't going to be great at it.
– If you don't put (not so) EZ-IOs into small kids a lot, consider using a manual IO. I personally think they are a lot harder to screw up. When I wasn't working primarily in peds, I would use EZ-IO for adults and manual IOs for small kids (<10kg). I really like the Jamshidis because they have an adjustable flange so you can set the maximum depth.
– Once you get the IO in, flush vigouorously, look for an signs of infiltration, then SECURE THE HECK OUT OF IT. Any movement of the catheter increases the risk of infiltration. Be vigilant about checking for infiltration and checking distal perfusion.
– As Minh suggested, an IO is only a temporary solution. As soon as the patient is stable enough or has enough intravascular volume get a peripheral or central line in them as their status warrants.
– Some people have suggested that the proximal humerus might be a prefered site both for flow rates and patient comfort. I have no experience with this, but I wonder if, in peds, it might lead to a lower infiltration rate due to the larger medullary space.
How to Secure an IO
Here’s a link to some pictures I took this morning…
http://db.tt/WnzgZkFY
If you are using a Jamshidi or another kind of IO catheter with a flange that rests on the skin, you can start with a couple pieces of tape over the flange.
If you don’t have a flange, take a piece of tape about 4-5? long and split it lengthwise about halfway down. Place the unsplit part on the skin and wrap the split ends around the hub of the IO catheter. I do this three times, spaced equally around the hub. (In case it isn’t clear, the coffee cup in the pictures represents the patient’s leg and the sharpie is the IO catheter hub.)
If you want to use tegaderm, now would be the time to apply it.
The next step is to build up a bukly dressing around the hub of the IO catheter and distal end of the IV tubing. I use roller gauze/king but anything would work. (This is represented by Epi-pen trainers in the pictures.) Tape all of this down. If you can still see the hub, you haven’t used enough bulky dressing.
The next step might be the most important for keeping the IO in place over the next few hours. Tape down, TO THE PATIENT, the next 8-12? of IV tubing. Make sure all stopcocks and ports are accessible, but also make sure that there can be ABSOLOUTLEY NO tension put on the line.
Vidacare also makes a stabilizer for EZ-IO catheters. They look nice, but I don’t have any experience with these as they are a bit pricy. I would guess that they would need a bit of stabilization in addition to this device and they definitely need the IV tubing secured.
http://www.vidacare.com/EZ-IO/Products-Accessories.aspx (scroll down)
I hope this helps and I would love to hear if anyone has any other tips or tricks.
Rebecca
NREMT-P CCP-C
These comments were added
Minh Le Cong:
Don Diakow:
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Rebecca…….have used the Vidacare product numerous times and it works great. Like a large OP site with a hard plastic cover for the IO hub. The IV loop threads right over the stabilizer and with a few strips of tape can also be secured to the patient.
Professor
Chief, Division of Emergency Critical Care
Director, Resuscitation and Acute Critical Care Unit
Stony Brook Medicine
Stony Brook, NY, USA
No conflicts of interest (coi).
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Rebecca, awesome photos thankyou and love your tips on IO care.
One other tip from one of my colleagues. If small kid and worried you might insert IO straight through tibia, consider the greater trochanter of the femur. Biggest bone in body, easier target and reasonable cavity with less chance of going through other side with current generation of manual and semiautomatic IO devices.
He had to do this on a kid with meningococcal sepsis last month after multiple failed tibial and humeral IO attempts. Still wakes up in a cold sweat about that case.