EZ
from TELEFLEX

Arrow® EZ-IO® Intraosseous Vascular Access System

2017 The Science and Fundamentals
of Intraosseous Vascular Accessincluding Frequently Asked Questions
Teleflex Global Research and Scientific Services, a Division of Clinical and Medical Affairs

Intr
Acc

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2017 Third Edition
Introduction.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

8

Indications/Contraindications and General Intraosseous (IO) Use.  .  .  .  .  .  .  .  .  .  .  .  .  .  . 10
When can the Arrow® EZ-IO® Intraosseous Vascular Access Systemfrom Teleflex be used?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 10
In what type of clinical scenarios is IO vascular access used?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 10
Can the Arrow® EZ-IO® Intraosseous Vascular Access System Device
be used in the sternum?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 11
What is off-label use of the Arrow® EZ-IO® Device?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 11
Can nurses and medics perform IO device insertions?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 11
Do professional organizations support IO vascular accessfor clinical applications?. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 11
Is special training or certification required prior to using the
EZ-IO® Device?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 12

Anatomy and Physiology of the IO Space ..  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 12
How does the IO vascular access route work?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 12
Which insertion site works best?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 12
Anatomy.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 13
Physiology .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 13
Intramedullary pressure.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 14
During CPR: guidelines .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 14
Preclinical studies .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15
Clinical studies.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 17

Technique/Training .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 21
How should the skin be prepared for IO insertion?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 21
Is a local anesthetic necessary for EZ-IO® Device insertionin an alert patient?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 21
How is appropriate EZ-IO® Needle Set length determined?
Can the “pediatric” needle sets be used in adults, or “adult” needle
sets in pediatric patients?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 21
How deep should the EZ-IO® Needle Set be inserted into the bone?.  .  .  .  .  .  .  .  .  .  .  . 22

3

What if the driver seems to be losing power and slows down?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 22
What is the manual insertion technique when a driver is unavailable
or inoperable?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 23
How should the EZ-IO® Catheter be stabilized?. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 24
Should the EZ-Connect® be primed with fluid prior to use?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 24
Does the EZ-Connect® Extension Set meet hospital infection control standards?.  .  .  . 24
What is the EZ-IO® Needle Set made of?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 24
Is a syringe flush necessary after IO insertion?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 24
Is it necessary to flush the IO line with saline after infusing medications
via the IO route?. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 25
What flow rates can be achieved with the EZ-IO® Device? How canflow rates be optimized?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 25
Does the syringe flush have to be repeated with prolonged use? Will the
EZ-IO® Catheter become occluded if unused for a few hours?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 25
Can a heparin lock/saline lock be used to maintain patency of an IO line?
What should be done if the IO line clots?. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 25
Can another IO catheter be placed in the same bone immediately following
a failed insertion or infusion?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 26
What is proper EZ-IO® Catheter removal technique? . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 26
What can be done if the EZ-IO® Catheter breaks off the hub or is impossible
to remove by recommended methods?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 26
Does the insertion site leak after EZ-IO® Catheter removal?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 26
Does the insertion site require special dressing or care after device removal?.  .  .  .  .  . 26
Can a patient ambulate with a tibial IO catheter in place?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 26
Are there any exercise restrictions after EZ-IO® Catheter removal?. .  .  .  .  .  .  .  .  .  .  .  . 27

Flow rates and infusion under pressure .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 27
Flushing and flow rates.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 27
Infusing under pressure.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 27
Pressure pumps.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 27
Maximum pressures for infusion.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 28
High pressure infusions/power injection.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 28

4Selection of Appropriate Insertion Site and Needle Set.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 29
EZ-IO® Needle Set selection.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 30
Sternal site . . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 32
Proximal humerus.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 32
Drug delivery.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 33
Flow rates.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 33
Pain management.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 33
Can the proximal humerus site be used in the perioperative setting?.  .  .  .  .  .  .  .  .  .  . 34
EZ-IO Device proximal humerus identification and insertion technique.  .  .  .  .  .  .  .  .  .  .  . 34®

Proximal tibia.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 37
Proximal tibia insertion site identification – adults /adolescents /larger children.  .  .  .  . 37
Proximal tibia insertion site identification – neonates/infants/small children .  .  .  .  .  .  . 37
EZ-IO® Device proximal tibia insertion technique.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 38
Distal tibia . . . .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 39
Distal tibia insertion site identification– adults /adolescents /larger children. .  .  .  .  .  .  . 39
Distal tibia insertion site identification – neonates /infants /children.  .  .  .  .  .  .  .  .  .  .  .  .  . 39
EZ-IO® Device distal tibia insertion technique.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 39
Distal femur .	. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 40
Distal femur insertion site identification – neonates/infants /children.  .  .  .  .  .  .  .  .  .  .  .  . 40
EZ-IO® Device distal femur insertion technique.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 40

Care and Maintenance of the EZ-IO Catheter.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 41®

Confirming EZ-IO® Catheter placement.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 41
EZ-IO® Catheter patency ..  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 41
Pain management in conscious patients.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 41
Site maintenance/monitoring.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 42
Patient activity.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 43
Removal.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 43

EZ-IO Driver and Training Driver.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 44®

Useful Life of EZ-IO® Driver.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 44
Manual insertion technique.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 44
EZ-IO® Driver cleaning.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 45
EZ-IO® Driver sterilization. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 45

5

EZ-IO® Training Driver.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 46
Trigger guard/vascular access pack (VAP).  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 46

EZ-Connect Extension Set.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 46®

Infection prevention/control.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 46

Complications.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 47
What are the complications associated with IO vascular access?.  .  .  .  .  .  .  .  .  .  .  .  .  .  . 47
Will infusing drugs through the IO space cause long-term damage
to the bone marrow?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 47
Does IO insertion or infusion affect the growth plate in pediatric patients?.  .  .  .  .  .  . 47
Is fat embolism or thromboembolism an issue with IO infusion?. .  .  .  .  .  .  .  .  .  .  .  .  .  . 47
Is air embolism a possibility through an IO catheter?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 47
Does Teleflex track complications associated with the EZ-IO® Device?.  .  .  .  .  .  .  .  .  . 47

Intraosseous Complications.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 49
EZ-IO® Device complications.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 49
Compartment syndrome.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 51
IO access-associated compartment syndrome in the literature.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 51
Effects of IO access on growth plates and bone repair. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 53
Effect on epiphyseal (growth) plates .. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 53
Clinical research.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 53
Preclinical research.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 53
Bone repair after IO infusion.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 54
Embolism .	. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 55
Thromboembolism.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 55
Air embolism.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 55
Fat embolism.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 56
Osteomyelitis. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 57

Medications/Fluids.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 58
What fluids and medications can be infused via the IO route?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 58
What dosages are required for IO infusion compared with IV dosages?.  .  .  .  .  .  .  .  .  . 58
What medications have been administered successfully to date(via the IO route)?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 58
List of infusates delivered via the IO route.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 60

6Pain Management for IO Infusion.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 63
Conscious patients/lidocaine dosing.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 64
Technique.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 64

Pediatrics: Newborn, Infants, Children, and Adolescents . . . . . . . . . . . . . . . . . . . . . 66
EZ-IO® Device: indications in pediatric patients.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 67
Can a 25 mm or 45 mm needle set be used in a pediatric patient?. .  .  .  .  .  .  .  .  .  .  .  .  . 67
In newborns, infants, and children, how deep should the EZ-IO®
Needle Set be inserted?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 68
Is there a risk of over-penetration with the EZ-IO® Device?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 68
Is compartment syndrome of concern in pediatric patients?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 68
What is the risk of injury to the epiphyseal (growth) platein pediatric patients?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 68
What can be done to manage IO infusion pain in pediatrics?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 69
How much “dead space” is in the EZ-Connect® Extension Set
and IO catheters?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 69
For infants and small children, should the EZ-IO® Catheter be secured
in any special manner?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 69
General discussion of IO access in pediatrics including literatureand technique.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 70
Brief literature review.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 70
Effect on epiphyseal (growth) plates.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 71
Site selection and landmarks.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 72
Summary of insertion technique (after landmarks are locatedand general technique for all sites).  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 72

Laboratory Analysis/Blood Sampling.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 75
Are blood specimens drawn via the IO route adequate for laboratory analysis?.  .  .  .  . 75
Laboratory Analysis/Blood Sampling from IO Access.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 75
Summary and recommendations.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 76
Clinical studies.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 76
Preclinical studies.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 78
Technical considerations.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 80

7Induced Hypothermia by Intraosseous Access.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 83
Preclinical studies.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 83

Special Considerations.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 84
Can the EZ-IO® Catheter remain in place during a CT scan?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 84
Can the EZ-IO® Catheter remain in place during an MRI scan?. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 84
Can the EZ-IO® Device be used in patients with osteoporosis?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 84
Should an IO device be inserted in the humerus on the sameside as a mastectomy?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 84
Is IO access contraindicated in a patient with avascular necrosis?.  .  .  .  .  .  .  .  .  .  .  .  .  . 84
Is IO access contraindicated in osteogenesis imperfecta?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 84
Can an IO device be used in burn patients?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 85
Can the EZ-IO® Device be used in hyperbaric medicine?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 85

Research.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 85
Has research been conducted demonstrating the safety and efficacy of
IO vascular access?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 85
How does the EZ-IO® Device compare with other IO products?. .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 86

Teleflex Customer Service.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 87
Is there someone available at Teleflex to provide assistance?. .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 87
Where should EZ-IO® Device problems (or complications) be reported?. .  .  .  .  .  .  .  . 87
Is there more information available on the EZ-IO® Device(e.g. training, specifications)?.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 87

8

INTRODUCTION
We are pleased to provide you with the third edition of The Science andFundamentals of Intraosseous Vascular Access. This document represents the
body of knowledge garnered from years of research (clinical and preclinical),laboratory experimentation, clinical experience (end-users and researchers),
and expert opinion (intraosseous experts and subject matter experts).
The document is divided by topics into several sections. The first part of eachsection contains a list of short, concise responses to the most commonly asked
questions regarding IO vascular access. Where more detailed information andresearch is available, the reader is directed to the appropriate section. For clarity,
most citations and references are confined to the expanded, detailed sections.
Citations which are followed by the superscript TS indicate studies that have beensponsored in part or conducted by Teleflex Incorporated.
A superscript EO after a statement or title signifies information based on Expert
Opinion and will occur after relevant statements (in lieu of a cited reference).
Unless otherwise noted, expert opinion is provided by Teleflex Clinical andMedical Affairs.

9The authors of this document have examined the cited sources and made every
effort to assure the information provided is reliable, complete, and in accord
with the standards of current practice at the time of publication. Use of IO
access devices is the responsibility of the treating clinician, medical director, or
qualified prescriber.
We hope these answers will assist Teleflex team members and clinicians intaking full advantage of the benefits – and minimizing the risks – of IO vascularaccess and use of the Arrow® EZ-IO® Intraosseous Vascular Access System.
This document is disseminated for medical and scientific/educational purposes only, and somecited studies may contain references to indications for IO access or insertion sites that have notbeen cleared or approved by the U.S. Food and Drug Administration (FDA) or regulatory
authorities outside of the U.S. relating to the EZ-IO® Device (manufactured/marketed/distributedby Teleflex Incorporated). This information should not be construed to suggest that any Teleflex
product may or should be used in any manner that differs from its FDA-cleared or CE markregistered Indications/Directions for Use.
Third edition updates by Diana Montez RN BSN, Tatiana Puga BS, and Thomas Philbeck PhD MBA
Teleflex Global Research and Scientific Services, a Division of Clinical and Medical Affairs May 2017
© 2017 Teleflex Incorporated

INDICATIONS/CONTRAINDICATIONS AND GENERAL IO USE

Indications /Contraindications andGeneral IO Use

In What Type of Clinical Scenarios is IO
Vascular Access Used?
The following is an example of some of the typesof emergent/urgent situations or patient conditions
where intravenous access is difficult or impossible toWhen Can the Arrow® EZ-IO® Intraosseous
Vascular Access System from Teleflex
Be Used?
Indications for the Arrow® EZ-IO® Intraosseous
Vascular Access System:•

obtain in which IO vascular access may be beneficial:••humeral head (proximal humerus) of adult andpediatric patients, and the distal femur inpediatric patients when intravenous access isdifficult or impossible to obtain in emergent,urgent, or medically necessary cases for up to 24
hours in the U.S. and up to 72 hours in the EU.

•

Fracture in target bone•••

Bridge to central
venous catheter

•
•
•
•
•
•
•
•

Burns

Cardiac compromise
Dehydration
Diabetic ketoacidosis
Drug overdose
End stage renal•

Rapid sequence
Respiratory
Seizures/statusepilepticus

•
•
•
•
•

SepsisShock
Sickle cell crisis
StrokeTherapeutic
hypothermia

disease•

Major trauma

compromise/arrest

Cardiac arrest
Cardiac arrhythmias

Hypovolemia

intubation necessity•

placement

Contraindications for the EZ-IO® Device:••

Altered level ofconsciousness

The Arrow® EZ-IO® Device provides intraosseousaccess in the proximal tibia, distal tibia, andAnaphylaxis

indication

Hemodynamic
instability

Excessive tissue (severe obesity) and /or absenceof adequate anatomical landmarks (e.g. may
also be due to muscularity or variations in body
habitus or an under-developed humerus in an
infant/small child)••

Infection at area of insertion site
Previous, significant orthopedic procedure at thesite, prosthetic limb, or joint•

IO access (or attempted IO access) in targetedbone within past 48 hours

Non-urgent but medically necessary situations or
patient conditions where intravenous access isdifficult or impossible to obtain in which IO vascularaccess may be beneficial:•

Antibiotic therapy
needed

•
•
•
•

•
•

Chest pain
Dehydration

anesthesia

Patients requiring
access for induction•

Metabolic disorders
Need for general

Patients in pain

Sedation forprocedures needed•

Surgical procedures

10

11

INDICATIONS/CONTRAINDICATIONS AND GENERAL IO USE

Can the EZ-IO® Device Be Used in
the Sternum?

within their respective scope of licensure. These

The Arrow EZ-IO Sternal Intraosseous System anddirectives are occasionally modified as new medical

the Arrow EZ-IO T.A.L.O.N. (Tactically Advanced

technology becomes standard and accepted within

Lifesaving Intraosseous Needle) were originallythe healthcare industry.

®

®

laws, regulations (e.g. state practice acts), and

®

®

™

designed for use by the military and tactical medical
teams. For EZ-IO® products, only the EZ-IO® Sternal

RN: A licensed, qualified and trained registered nurse

Intraosseous System and the EZ-IO T.A.L.O.N. as

is permitted to place and manage IO devices, if it isdirected in the Instructions for Use specific to thedetermined by regulation, position statement or

sternum may be used safely in the sternum. Neither

decision-making model to be within that professional’s

the EZ-IO Needle Sets nor the EZ-IO Driver should

scope of practice. The appropriate organizational

ever be used for sternal insertion. Refer to theofficials, chief nursing officer/nurse supervisor,

indication for use in the Instructions for Use forhospital, or state regulatory official should be

the EZ-IO Sternal Intraosseous System and theconsulted to determine whether placement and use

EZ-IO T.A.L.O.N. Devices.

of IO devices is currently within an individual’s scope

™

®

®

®

®

®

™

of practice.

What is Off-Label Use of the
EZ-IO® Device?

EMT-P, EMT-I, EMT-B: Each state permits a

Off-label use is defined as use of a medical device

licensed, trained, and qualified EMS professional

for an indication not specifically approved or cleared

to place and use IO devices upon the order of aby the U.S. Food and Drug Administration (FDA)

medical director. The appropriate state regulatory

or governing regulatory body specific to countries

agency, medical director, and system protocols

outside of the United States. Physicians (or qualified

should be consulted to determine if placement andprescribers) may prescribe, order, or use drugs

management of IO devices is currently within an

and devices for indications not approved or cleared

individual’s scope of practice.

by the FDA according to their best medical
judgment; however, the manufacturing company is

Do Professional Organizations Support IO

prohibited from any promotion of the off-label use.

Vascular Access for Clinical Applications?

Therefore, Teleflex does not recommend, promote,A variety of professional organizations haveor endorse off-label use of the EZ-IO® Device.1

developed position statements and guidelines
supporting IO vascular access for their

Can Nurses and Medics Perform
IO Insertions?
Every state has laws and regulations that govern the
medical procedures licensed personnel may perform

respective specialties.2-9

ANATOMY AND PHYSIOLOGY OF THE IO SPACEIs Special Training or Certification
Required Prior to Using the EZ-IO® Device?

6

International Association of Flight Paramedics Critical Care
Paramedic Position Statement. International Association of
Flight and Critical Care Paramedics website. http://c.ymcdn.com/

There is no official “certification” process unlesssites/iafccp.site-ym.com/resource/resmgr/docs/critical_care_mandated by an agency/organization, medical

paramedic_posi.pdf?hhSearchTerms=%22intraosseous%22.

director, or hospital. The EZ-IO Needle Set is

Published July 2009. Accessed March 20, 2017.

®

similar to a peripheral intravenous (IV) catheter in7

intraosseous infusion in pediatric anesthesia. Anasth Intesivmedthat specific training must occur in order to use
the device safely and correctly. Teleflex offers a

Eich C, Weiss M, Neuhaus D, et al. Working guidelines for
2011; 52:46–52.

8

Bodenham A, Babu S, Bennett J, et al. Association of Anaesthetists

comprehensive training program for the EZ-IO®

of Great Britain and Ireland: Safe Vascular Access 2016 Guidelines.

Device and recommends completion prior toAnaesthesia 2016;71:573–585. doi:10.1111/anae.13360.

using the device. Online training information isavailable at www.teleflex.com/ezioeducation.
Additionally onsite training can be requested

9

Rhodes A, Evans LE, Alhazzani W et al. Surviving sepsis
campaign: international guidelines for management of sepsis
and septic shock. Intensive Care Med 2017:1-74. doi:10.1007/
s00134-017-4683-6.

through your local Teleflex representative or byemail: CMARequest@teleflex.com.
1

Food and Drug Administration. “Off-Label” and Investigational
Use Of Marketed Drugs, Biologics, and Medical Devices

Anatomy and Physiologyof the IO Space

Information Sheet. Internet: Accessed: 05/30/2017. Available at:Phillips L, Brown L, Campbell T, Miller J, Proehl J, Youngberg B.

How Does the IO Vascular Access
Route Work?

Recommendations for the use of intraosseous vascular access

IO vascular access catheters are usually placed in

https://www.fda.gov/regulatoryinformation/guidances/cm126486
2

for emergent and nonemergent situations in various healthcare
settings: a consensus paper. J Emerg Nurs 2010;36(6):551-6.

3

doi:10.1016/j.jen.2010.09.001

bones due to the thinner compact bone andInfusion Nurses Society. The role of the registered nurse in theabundance of cancellous (spongy) bone at these

insertion of intraosseous access devices. J Infus Nurs 2009;sites. Within the epiphysis of the medullary space32(4):187-8.
4

the proximal and distal ends (epiphyses) of long

Fowler R, Gallagher JV, Isaacs SM, Ossman E, Pepe P, Wayne W.
The role of intraosseous vascular access in the out-of-hospitallies a vast system of blood vessels. When accessedwith an IO catheter, infusions pass from theenvironment (resource document to NAEMSP position

medullary space through the vascular system into

statement). Prehosp Emerg Care 2007;11:63-6. doi:10.1080/

the central circulation.

10903120601021036.
5

Alternative methods to vascular access in the emergency
department. American College of Emergency Physicians website.

Which Insertion Site Works Best?

https://www.acep.org/Clinical---Practice-Management/Alternative-

IO site selection depends on clinical needs, patient

Methods-to-Vascular-Access-in-the-Emergency-Department/#sm.

age, size, anatomy, presenting condition, ability to

00000zo2t9980ce5apox4cr26p5hu. Published June 2011.

locate anatomical landmarks, environment, clinicalAccessed 02/08/17.

12

13

ANATOMY AND PHYSIOLOGY OF THE IO SPACE

judgment, and experience. [See Selection ofarea of the bone allows for easier entry throughAppropriate Insertion Site and Needle Set, page 29]

the cortex of the bone, with rapid access into theIO vasculature.

AnatomyWithin the epiphysis (proximal and distal end) of

Physiology

the medullary space of the bone lies a vast system of

A 25-patient clinical study published in 2008

blood vessels and sinusoids, the Haversian canals andcompared the pharmacokinetics of IO access using

Volkmann canals, which function as rigid non-an implantable IO device to IV administration ofcollapsible canals. During IO infusion to this largemorphine sulfate in adults. The investigators reported

network, blood and fluid travel quickly through thisno differences between IO and IV administration ofcomponent of the vascular system out nutrient andmorphine for several pharmacokinetic parameters,

emissary vessels to reach the central circulation.

including maximum plasma concentration, time to

See Figure 1 below and Figure 2 on following page.

maximum plasma concentration, and area under

1,2

plasma concentration-time curve.3
IO vascular access catheters are placed in theepiphyses of long bones such as the humerus andIn a healthy adult volunteer study, contrast media

tibia where compact bone is relatively thin and there

was injected through the proximal humerus site andis an abundance of cancellous (spongy) bone. This

captured under fluoroscopy as it entered the heart.

Figure 1

Cancellous
bone

Corticalbone

OsteonPeriosteum
ArteryVein
Haversian canals

VolkmanncanalANATOMY AND PHYSIOLOGY OF THE IO SPACE

Figure 2

Compact bone(thin wall)
Cancellous bone
Vein
Epiphysis

Medullary cavity
Compact bone(thick wall)

Diaphysis

Tibia

The mean time it took from injection at the insertion

obtained using an external blood pressure cuff.

site to visualize contrast entry from the superior

Investigators concluded that in severely ill andvena cava into the right atrium was 2.42 seconds.

injured patients, IO pressure can be reliably

Many preclinical and clinical studies support theobtained and appears to be 35% to 40% of blood

safety, efficacy and ease of use of the IO vascularpressure readings obtained via an external blood

access route for administration of a variety of fluids

pressure cuff.20

4and medications in multiple applications.5-17
bibliography listing intraosseous vascular access

During Cardiopulmonary Resuscitation(CPR)

publications is available at: http://www.teleflex.com/

Guidelines. As early as 1992, a statement for the

en/usa/ezioeducation/documents/General_IO_

Advanced Life Support Working Party of the

Bibliography.pdf

European Resuscitation Council (ERC) describes the

For additional resources, a comprehensive

IO route as a rapid route to central circulation and a

Intramedullary Pressure

viable route for drug administration during CPR.21

Two preclinical studies demonstrated pressure in

In a 1996 article, physicians from Japan described

the IO medullary cavity measures approximately

successful experiences using the IO route for

22% to 25% of arterial pressure without significant

resuscitation medications during CPR.22 Since

difference between IO sites tested.18,19 A clinical pilot

2005, the American Heart Association acknowledges

study by the same researchers was conducted with

the intraosseous route to enable delivery similarintensive care unit patients to measure IO pressures

to peripheral access and advocates use of theand determine their relationship to blood pressure

intraosseous route for medication administration

14

15

ANATOMY AND PHYSIOLOGY OF THE IO SPACE

as a priority after CPR and rapid defibrillation. It

gains access to the central circulation ranging

states IO access is reasonable if IV access is notfrom less than one minute for the sternal IO site

readily available. Since 1988, Pediatric Advanced

to less than two minutes from the tibia, yielding

Life Support (PALS) guidelines recommend imme-

physiologically significant levels even during

diate intraosseous access in cardiac arrest if no IV

CPR.27,28 The authors suggested that results

access is in place; limiting number of attempts fordemonstrated IO access equivalence to IV accessvenous access; and establishing intraosseous accessduring CPR. The same investigators completed a

if IV access cannot be attained quickly. PALS states

follow up study evaluating the sternal and humeral“IO access can be quickly established with minimal

IO (HIO) routes and concluded the proximal

complications by providers with varied levels of

humerus and sternal IO routes were comparable

training”; and recommends limiting time spentto central venous drug delivery during CPR.29,30

23

establishing IV access. PALS notes “and it is usefulas the initial vascular access in cases of cardiac

In a 2011 preclinical study by Zuercher et al., 30

arrest (Class I, LOE C). Many intravenous medications

swine in ventricular fibrillation with continuous

can be administered intraosseously, including

chest compressions received IO epinephrine, IV

epinephrine, adenosine, fluids, blood products, andepinephrine, or placebo. Return of spontaneous

catecholamines (as referenced in clinical literature).

circulation (ROSC), 24-hour survival, and 24-hour

Onset of action and drug levels for most drugs are

survival with good neurological outcome were

The 2015

evaluated. Results showed ROSC to be nearlycomparable to venous administration.”

24

ERC guidelines reiterate that IO access is a rapid,

universal for the IV and IO groups with nosafe, and effective vascular access route; and notedifferences between rates; 24-hour survival wasthat the onset of action and time to achieve

substantially more likely in the IO group than theadequate plasma drug concentrations are similar

IV group; survival with good neurological outcome

to that achieved via the central venous route andwas more likely in the IO group than the IV group.31

recommends it as a viable route for drug
Another swine study, by Burgert et al., comparedadministration during CPR.25

epinephrine concentrations administered via the

Preclinical Studies

tibial IO (TIO), sternal IO, and IV routes during

Preclinical studies dating to 1990s have studied the

CPR. The IV route of administration of 1 mg ofefficacy of IO access during CPR. In a series of

epinephrine resulted in a serum concentrationpreclinical swine studies, Hoskins et al. evaluatedgreater than the tibial route and sternal route,efficacy of the IO route compared to other IV

respectively. The times to peak concentration wasaccess routes. In the early studies researcherssimilar for IV and sternal IO groups but delayeddemonstrated that fluid infused into the IO space

for the tibial route. Authors concluded that due

26

ANATOMY AND PHYSIOLOGY OF THE IO SPACE

to limitations of their study the guidelines offrom the heart did not affect short-term measures ofadministering 1 mg of epinephrine via the IO route

resuscitative outcome in an adult swine model of VF

should not be changed; further studies using larger

including the occurrence of ROSC, 30-minutesample size, larger volume flush, arterial blood

post-ROSC survival, and time to ROSC. Rapidly

samples, and the use of a more precise method ofadministered epinephrine, irrespective of route ofmeasuring serum epinephrine should be done.

administration, increased the chance of ROSC and32

survival to 30 minutes post-ROSC in this study.34
A 2015 follow-up prospective preclinical study
by some of the same investigators was done to

A number of preclinical studies published in 2016

determine the effects of HIO and IV epinephrine

studied IO delivery of medications during CPR on

administration during cardiac arrest on

ROSC and their pharmacokinetic qualities in a swine

pharmacokinetics, ROSC, and odds of survival.

model. Wimmer et al. compared pharmacokinetics

There were no significant differences in ROSC,

of IO humeral vasopressin and ROSC with IV accessmaximum concentration, except at 30 seconds,

and a control of defibrillation and CPR only. All IO

and time-to-concentration-maximum between theaccess animals had ROSC; hemodynamic and

HIO and IV groups. Significant differences existed

pharmacokinetic parameters and survivability were

between the experimental groups and the control.

no different for the IO and IV groups. Survivability

The HIO delivered a higher concentration of

was 33 times higher for the IO group versus the

epinephrine than the IV route at 30 seconds, which

control group (p = 0.03).35 Amniodarone given by

they noted may be a survival advantage. Authors

the IV route was compared to administration by thesuggested clinicians consider using the IO route

IO route via the tibial, humeral, and sternal sites into administer epinephrine when IV accessthree other studies. In a comparison of the HIO andis unobtainable.

IV routes, Holloway et al. found no difference in

33time to ROSC or rate, time to maximum concentraA 2015 preclinical randomized controlled trial (RCT)tion (Tmax) (p = 0.501) or in maximum plasma drugby Burgert et al. evaluated the relationships between

concentration (Cmax) (p = 0.232).36 In a comparison of

the anatomical distance of IO epinephrine and

IV to TIO administration of amniodarone

measures of resuscitative outcome in an adult swine

investigators found no significant differences for themodel of ventricular fibrillation (VF). There were nosame endpoints between IO and IV.37 The sternalsignificant differences between the HIO, TIO, and IV

route was compared to IV in a hypovolemic cardiac

groups relative to the occurrence of ROSC, 30-minutearrest swine model for Cmax, Tmax, and ROSC rates

post-ROSC survival, and time to ROSC. The

and times. No significant differences were found in

anatomical distance of IO epinephrine injection

this study between IO and IV administration.38

16

17

ANATOMY AND PHYSIOLOGY OF THE IO SPACE

Two recently published preclinical studies addressed

Clinical Studies

IV versus IO delivery of resuscitative medications

Clinical studies reporting on IO vascular accessduring CPR. Wong 2016 examined the differences

most often report the ease of access and successin pharmacokinetics and pharmacodynamics of TIO

rates with few reporting on rates of ROSC.42-46

and IV-delivered epinephrine during cardiac arrest

Due to the anatomical characteristics of the mostand CPR. There were no significant differences

commonly accessed IO insertion sites in the

between IV versus TIO epinephrine in achieving

extremities, IO access can be obtained without or

ROSC, time to ROSC, and Cmax (the maximum

with minimal interruption of chest compressions.16

concentration). Authors suggest that in the context
of ROSC, epinephrine delivered via the TIO

Ross 2016 compared IO versus IV access for theroute is a clinically relevant alternative to IV

time to epinephrine for out of hospital cardiac

administration. In another study using a swinearrests (OOHCA). There were 2,601 cases of IO

model, Fulkerson et al. completed a randomized

usage and 55 cases of PIV usage. From arrival at theprospective study to examine the differences inpatient’s side to administration of the first dose ofpharmacokinetics and pharmacodynamics of TIO

epinephrine the mean time was 5.0 minutes (95%and IV-delivered vasopressin during cardiac arrest

CI: 4.7 min to 5.4 min) for the IO group and 8.8

and CPR until ROSC was achieved. No difference

minutes (95% CI: 6.6 min to 10.9 min) for thewas noted for ROSC between TIO and IV delivered

PIV group (p < 0.001). In this study the proximal

vasopressin. Authors concluded use of IO accesshumerus was the site most commonly accessed

could avoid the time delay associated with IV

at 86.2% with a 95.65% first attempt success

access, is effective for treatment of hypovolemic

rate. Authors recommended the use of IO vascularcardiac arrest and should be first line for rapid

access for time-dependent medical conditions for

vascular access.

out-of-hospital situations.47

Burgert 2017 reported data from a preclinical study

A recent retrospective study by Clemency et al.

evaluating the pharmacokinetics of HIO and IV

compared the rates of emergency department (ED)vasopressin and the ROSC in a swine model of

ROSC between IO and peripheral IV (PIV) vascular

ventricular fibrillation cardiac arrest. For theaccess in OOHCA. For 788 (60.15%) subjects,

parameters of occurrence of ROSC, odds of ROSC,

EMS providers attempted PIV access first. In 552

time to ROSC, Cmax, Tmax, and plasma concentra-(39.85%) subjects IO access was the first method

tions over time, the IO and IV routes results werefor vascular access. ROSC at time of ED arrival rates

comparable.

were 19.67% for PIV access and 19.92% for IO

39

40

41

access. Based on the primary end point ROSC at

ANATOMY AND PHYSIOLOGY OF THE IO SPACE

time of ED arrival, the IO approach was non-suggested IO placement was not associated withinferior to the PIV approach (p = 0.01); and IO access

improved survival for adults in OOHCA.52

had superior first attempt success rates comparedto PIV. Investigators noted this study represents
evidence supporting the AHA guidelines stating “it1

Paxton JH. Intraosseous vascular access: A review. Trauma
2012;14(3):195-232. doi:10.1177/1460408611430175.

2

Atanda A Jr, Statter MB. Compartment syndrome of the leg

is reasonable for providers to establish IO access if

after intraosseous infusion: guidelines for prevention, early

IV access is not readily available (Class IIa, LOE C).”

detection, and treatment. Am J Orthop 2008;37:E198-200.

Authors noted a limitation of their study was that3

equal intravenous? A pharmacokinetic study. Amer J Emerg Med

it did not report on final neurological outcomes forincluded patients.25,48

Von Hoff DD, Kuhn JG, Burris HA, Miller LJ. Does intraosseous
2008;26:31-8.

4Montez DF, Puga T, Miller L, et al. Intraosseous infusions fromthe proximal humerus reach the heart in less than 3 seconds
in human volunteers. Ann Emerg Med 2015;66(4):S47TS

Bramlett 2016 also conducted a retrospective study

http://dx.doi.org/10.1016/j.annemergmed.2015.07.165.

on approximately 800 cases of OOHCA in which
they found a significantly greater insertion success5

needles for injection of contrast media for computed tomographic

rate for IO access but no difference between IO andangiography of the thoracic aorta. J Cardiovasc Comput Tomogr
2017; article in press. http://dx.doi.org/10.1016/j.jcct.2017.03.

IV for ROSC or time to first epinephrine. In a study
49

001.TS

done in Singapore conducted by Chin et al., theobjective was to determine if there would be

6

Lewis P, Wright C. Saving the critically injured trauma patient:a retrospective analysis of 1000 uses of intraosseous access.

a difference in rates of vascular access and ROSC
if paramedics were able to use IO access after

Winkler M, Talley C, Wodward C, et al. The use of intraosseousEmerg Med J 2014. doi:10.1136/emermed-2014-203588.
7

Hamed RK, Hartmans S, Gausche-Hill M. Anesthesia throughtwo initial IV attempts failed. Investigators foundan intraosseous line using an 18-gauge intravenous needle forhigher vascular access success and pre-hospitalemergency pediatric surgery. J Clin Anesth 2013;25(6):447-451.
doi:10.1016/j.jclinane.2013.03.013. http://dx.doi.org/10.1016/j.

epinephrine administration rates with the addition
of IO access but no significant difference for ROSC.50

jclinane.2013.03.013.
8

Aliman AC, Piccioni Mde A, Piccioni JL, Oliva JL, Auler Junior JO.

A small hospital study by Lantos 2015 describes

Intraosseous anesthesia in hemodynamic studies in children

data from a 2013 policy change which allowed rapid

with cardiopathy. Rev Bras Anestesiol 2011;61(1):41-9.

response team nurses to place IO access forin-hospital cardiac arrests. Prior to the change themean time to first medication was 4.3 minutes with

9

Loughren M, Banks S, Naluan C, Portenlanger P, Wendorf A,
Johnson D. Onset and duration of intravenous and intraosseousrocuronium in swine. West J Emerg Med 2014;XV(2):241-5.

10 Barnard EBG, Moy RJ, Kehoe AD, Bebarta TS, Smith JE. Rapid

53.1% patients surviving to ICU. Post-policy change

sequence induction of anesthesia via the intraosseous route: apatients that received IO access had a mean time

prospective observational study. Emerg Med J 2014. doi:10.1136/

to medication of 1.7 minutes and 85.7% survival to
ICU.51 An earlier study of 22 patients with OOHCA

emermed-2014-203740.

18

19

ANATOMY AND PHYSIOLOGY OF THE IO SPACE

11 Bebarta TS, Vargas TE, Castaneda M, Boudreau S. Evaluation

23 Neumar RW, Otto CW, Link MS, et al. Adult advancedof extremity tissue and bone injury after intraosseous hypertonic

cardiovascular life support. 2010 American Heart Association

saline infusion in proximal tibia and proximal humerus in adult

guidelines for cardiopulmonary resuscitation and emergency

swine. Prehosp Emerg Care 2014. doi:10.3109/109031.27.2014.

cardiovascular care. Circulation 2010;122(suppl 3):S729-67.

912704.

doi:10.1161/circulationha.110.970988

12 Schlimp CJ, Solomon C, Keibl C, et al. Recovery of fibrinogen

24 Kleinman ME, Chameides L, Schexnayder SM et al. Part 14:

concentrate after intraosseous application is equivalent to thePediatric advanced life support: 2010 American Heart Association

intravenous route in a porcine model of hemodilution. J Trauma

guidelines for cardiopulmonary resuscitation and emergency

Acute Care Surg 2014;76(5):1235-42.

cardiovascular care. Circulation 2010;122:S876–S908.

13 Spencer TR. Intraosseous administration of thrombolytics for

25 Monsieurs KG, Nolan JP, Bossaert LL et al. European

pulmonary embolism. J of Emerg Med 2013. http://dx.doi.org/

Resuscitation Council guidelines for resuscitation 2015-Section 1.

10.1016/j.jemermed.2013.05.057.

Executive summary. Resuscitation 2015;95:1-80

14 Johnson D, Dial J, Ard J, et al. Effects of intraosseous and

26 Krol LV. Plasma epinephrine concentrations after intraosseous

intravenous administration of Hextend on time of administrationand central venous injection during cardiopulmonary

and hemodynamics in a swine model. J Spec Oper Med 2014;

resuscitation in the lamb. J Emerg Med 1991;9(1-2):89.

14(1):79-85.
15 Chansa E, Kansen K, Gustafsson B. An intraosseous bloodtransfusion in a critically ill child [Une transfusion sanguine parvoie intraosseuse chez un enfant gravement malade]. Afr J Emerg
Med 2013. http://dx.doi.org/10.1016/j.afjem.2013.05.003.
16 Anson JA. Vascular access in resuscitation: Is there a role forthe intraosseous route? Anesthesiology 2014;120(4):1015-31.
17 Anson JA, Sinz EH, Swick JT. The versatility of intraosseous

27 Hoskins S, Nascimento P, Espana J, Kramer G. Pharmacokinetics
of intraosseous drug delivery during CPR. Shock 2005;23:35.TS
28 Hoskins S, Stephens C, Kramer G. Efficacy of intraosseous drugdelivery during cardiopulmonary resuscitation in swine. Paper
presented at the annual meeting of the National Association of
EMS Physicians, Registry Resort, Naples, FL. <Not Available>.
2013-12-17 from http://citation.allacademic.com/meta/
p64887_index.html. Accessed 05/29/17.

vascular access in perioperative medicine: a case series. J Clin

29 Hoskins SL, Nascimento P Jr., Lima RM, Espana-Tenorio, JM,

Anesth 2015. http://dx.doi.org/10.1016/j.jclinane.2014.10.002.

Kramer GC. Pharmacokinetics of intraosseous and central

18 Frascone RJ, Salzman JG, Bliss P, Adams A, Wewerka SS,
Dries DJ. Intraosseous pressure tracings mimic arterial pressure
tracings in timing and contour. Ann Emerg Med 2013;62(4s):s13.TS
19 Frascone RJ, Salzman JG, Adams AB, Bliss P, Wewerka SS,
Dries DJ. Evaluation of intraosseous pressure in a hypovolemic
animal model. J Surg Res 2015;193:383-390. http://dx.doi.org/
10.1016/j.jss.2014.07.007.TS
20 Salzman JG, Frascone RJ, Zagar AE et al. Intraosseous pressure
monitoring in critical care patients. Ann Emerg Med 2015;66(4s):
S148.

TS

21 Hapnes SA, Robertson C. CPR–drug delivery routes and systems.
A statement for the advanced life support working party of theEuropean Resuscitation Council. Resuscitation 1992;24:137-42.
22 Iwama H, Katsumi A. Emergency fields, obtaining intravascularaccess for cardiopulmonary arrest patients is occasionallydifficult and time-consuming. J Trauma 1996;41:931-2.

venous drug delivery during cardiopulmonary resuscitation.
Resuscitation 2012;83(1):107-12.TS
30 Hoskins SL, Zachariah BS, Copper N, Kramer GC. Comparisonof intraosseous proximal humerus and sternal routes for drugdelivery during CPR. Circulation 2007;116:II_993.TS
31 Zuercher M, Kern KB, Indik JH, et al. Epinephrine improves
24-hour survival in a swine model of prolonged ventricularfibrillation demonstrating that early intraosseous is superior todelayed intravenous administration. Anesth Analg 2011;112(4):884-90. doi:10.1213/Ane.0b013e31820dc9ec.
32 Burgert J, Gegel B, Loughren M. Comparison of tibial
intraosseous, sternal intraosseous, and intravenous routes ofadministration on pharmacokinetics of epinephrine during
cardiac arrest: A pilot study. AANA Journal 2012;80(4):S6-S10.

ANATOMY AND PHYSIOLOGY OF THE IO SPACE

33 Johnson D, Garcia-Blanco J, Burgert J, et al. Effects of humeral

43 Wampler D, Schwartz D, Shumaker J, Bolleter S, Beckett R,

intraosseous versus intravenous epinephrine on pharmacokinetics

Manifold C. Paramedics successfully perform humeral EZ-IO®

and return of spontaneous circulation in a porcine cardiac arrest

intraosseous access in adult out-of-hospital cardiac arrest

model: A randomized control trial. Ann Med Surg 2015;4(3):patients. Am J Emerg Med 2012;30:1095-9. doi:10.1016/j.ajem.

306-310. doi:10.1016/j.amsu.2015.08.005.

2011.07.010.TS

34 Burgert JM, Johnson AD, Garcia-Blanco J et al. The effects

44 Gazin N, Auger H, Jabre P, et al. Efficacy and safety of theof proximal and distal routes of intraosseous epinephrine

EZ-IO® intraosseous device: Out-of-hospital implementation ofadministration on short-term resuscitative outcome measuresa management algorithm for difficult vascular access.

in an adult swine model of ventricular fibrillation: a randomized

Resuscitation 2011;82(1):126-9.

controlled study. Am J Emerg Med 2016;34(1):49-53. doi:10.1016/
j.ajem.2015.09.007. Epub 2015 Sep 21.
35 Wimmer MH, Heffner K, Smithers M, et al. Am J Disaster Med
2016;11(4):237-242.
36 Holloway MM, Jurina SL, Orszag JD, et al. Effects of humerus

45 Guyette FX, Rittenberger JC, Platt T, Suffoletto B, Hostler D,
Wang HE. Feasibility of basic emergency medical technicians toperform selected advanced life support interventions. Prehosp
Emerg Care 2006;10(4):518-21.
46 Reades R, Studnek JR, Vandeventer S, Garrett J. Intraosseous

intraosseous versus intravenous amiodarone administration in

versus intravenous vascular access during out-of-hospitala hypovolemic porcine model. Am J Disaster Med 2016;11(4):cardiac arrest: a randomized controlled trial. Ann Emerg Med

261-269.

2011;58(6):509-16. doi:10.1016/annemergmed.2011.07.020.

37 Hampton K, Wang E, Argame JI, Bateman T, Craig W, Johnson D.

47 Ross EM, Mapp J, Kharod CU. Time to epinephrine in out-of-

The effects of tibial intraosseous versus intravenous amiodarone

hospital cardiac arrest: A retrospective analysis of intraosseousadministration in a hypovolemic cardiac arrest porcine model.

versus intravenous access. Ann Emerg Med 2016;68(4s):S61.

Am J Disaster Med 2016;11(4):253-260.
38 Smith S, Borgkvist B, Kist T, Annelin J, Johnson D, Long R. The

48 Clemency B, Tanaka K, May P, et al. Intravenous vs. intraosseousaccess and return of spontaneous circulation during out ofeffects of sternal intraosseous and intravenous administration of

hospital cardiac arrest. Am J Emerg Med 2016; accepted

amiodarone in a hypovolemic swine cardiac arrest model. Am J

manuscript. http://dx.doi.org/10.1016/j.ajem.2016.10.052.

Disaster Med 2016;11(4):271-277.

49 Bramlett E, Fales W, West B, LaBond V. Rate of return of

39 Wong MR, Reggio MJ, Morocho FR, et al. Effects of intraosseous

spontaneous circulation in relation to primary vascular accessepinephrine in a cardiac arrest swine model. J Surg Res 2016;

during out-of-hospital adult cardiac arrest. Ann Emerg Med

201:327-33. doi:10.1016/j.jss.2015.11.015.

2016;68(4S):S120.

40 Fulkerson J, Lowe R, Anderson T, Moore H, Craig W, Johnson D.

50 Chin YX, Kiat Tan KB, Koh ZX, et al. Comparing intraosseous

Effects of intraosseous tibial vs. intravenous vasopressin in aand intravenous access for out-of-hospital cardiac arrest in

hypovolemic cardiac arrest model. West J Emerg Med 2016;17(2):Singapore. Resuscitation 2016;106S:e25. http://dx.doi.org/

222-8. doi:10.5811/westjem.2015.12.28825.

10.1016/j.resuscitation.2016.07.054.

41 Burgert JM, Johnson AD, Garcia-Blanco J, Fulton LV, Loughren

51 Lantos D, Goforth D. Intraosseous needles reduce time to first

MJ. The resuscitative and pharmacokinetic effects of humeral

medication for coding inpatients without intravenous access.

intraosseous vasopressin in a swine model of ventricular

Crit Care Nurse 2015;35(2):e69.

fibrillation. Prehosp Disaster Med 2017;32(3):1-6.
42 Isayama K, Nakatani T, Tsuda M, Hirakawa A. Current status ofestablishing a venous line in CPA patients by emergency lifesaving technicians in the prehospital setting in Japan and a
proposal for intraosseous infusion. Int J Emerg Med 2012;5(2):http://www.intjem.com/content/5/1/2.

52 Schutt RC, Bowman B, Cevik C, et al. Intraosseous line placement
does not improve outcome in adults with out-of-hospital
cardiac arrest. Prehosp Emerg Care 2009;13(1):102.

20

21

TECHNIQUE/TRAINING

Technique/Training

For more comprehensive information about lidocaine
dosing regimens, please refer to the Teleflex web site:www.eziocomfort.com.

Note
For comprehensive training information, please1

refer to the Teleflex web site www.teleflex.com/

infusion using a temporary solution. Crit Care Med 2016;44(12):ezioeducation or contact Customer Service/
Clinical Support at 866.479.8500. For calls
outside the U.S., please dial +1.866.479.8500.

How Should the Skin Be Prepared for
IO Insertion?

Davlantes C, Puga T, Montez D, Philbeck T, Miller L, DeNoia E.
48 hours dwell time for intraosseous access: A longer-term
140.TS

2Montez D, Puga T, Davlantes C, Philbeck T. IO infusion pain
mitigation in the sternum and proximal humerus: Establishinga regimen. Crit Care Med 2016;44(12):154TS

site should be thoroughly cleaned using a clean, no-

How is the Appropriate EZ-IO® Needle Set
Length Determined? Can the “Pediatric”
Needle Sets be Used in Adults, or “Adult”
Needle Sets in Pediatric Patients?

touch technique with antiseptic solution (commonly

The EZ-IO® Needle Sets are based on approximate

referred to as “aseptic”) per your protocol.

weight and not classified as “pediatric” or “adult”.

Similar to a peripheral IV site: prior to insertion, theThe needle sets are 15 gauge and available in three

Is a Local Anesthetic Necessary for an
EZ-IO® Device Insertion in an Alert Patient?

different lengths including 15 mm (for 3 to 39 kg),

EZ-IO Needle Set insertion does not generally

and/or excessive tissue depth). Clinical judgment

require local soft tissue anesthesia, but discomfort

should be used to determine appropriate needle set

resulting from the insertion is variable, so local

selection based on patient anatomy, weight, andinfiltration of an anesthetic prior to insertion may betissue depth. For example, a small adult may require

done if the clinician desires. However, the rapid flusha shorter length catheter whereas an obese childof saline required after initial insertion is often painful

may require a longer catheter. The longer 45 mm

for patients responsive to pain; therefore following

needle set should be used when there is excessive

the IO needle insertion, anesthetic (preservative-freetissue overlying the insertion site for any patientand epinephrine-free intravenous lidocaine) delivered

40 kg or over, and for the proximal humerus site inslowly through the IO catheter into the medullarymost adults.

®

25 mm (3 kg or over), and 45 mm (40 kg or overspace may be considered for use under institutional
protocols or policies. In general, the infusion of fluids

The EZ-IO® Catheter is marked with black lines

at normal flow rates does not cause significant pain

starting approximately 5 mm from the hub. Withor discomfort.

every insertion, the needle set should be used as a

1,2

TECHNIQUE/TRAINING“depth gauge” to measure tissue depth to determine

to prevent undesired pressure on the skin around

if the needle set is the correct length for the patient

the insertion site which may cause skin injury.

prior to powering the needle set (or manuallyinserting) past the outer cortex and into thePediatrics: Immediately release the trigger whenmedullary space. Indications that the needle set isyou feel the “pop” or “give” as the needle set enters

not long enough include the following: the needle

the medullary space.

set does not reach bone or no black lines are visible
above the skin with the tip of the needle set touching

Adults: Gently drill into the medullary space untilbone. If those conditions occur, the inserter musta loss of resistance is felt (approximately 1-2 cm)

choose a longer length needle set or re-evaluate theor until the needle set hub is close to or flush with,choice of a particular site for insertion. Failure to

but not pressed into, the skin to avoid undesired

see at least one black line depth mark is an indicationpressure on the skin around the insertion site. The

for the clinician that the needle is too short and will

decreased resistance indicates entry into the

not reach the medullary cavity, which may result in

medullary space. In the humerus, for most adults a

inadequate IO access. Using a needle set that is too

45 mm needle set should be advanced until catheter

short will increase the risk of catheter dislodgement;

hub is flush with the skin.

inserting too deeply may breach the opposite cortex.
Both situations can potentially lead to infiltration/

Clinicians are strongly encouraged to study the

extravasation. [See Selection of Appropriate

training materials and obtain hands-on experience

Insertion Site and Needle Set, page 29]

with a Teleflex Arrow® EZ-IO® Clinician for safe andproper use of the EZ-IO® Device. [See Selection of

How Deep Should the EZ-IO® Needle Set

Appropriate Insertion Site and Needle Set, page 29]

Be Inserted into the Bone?

[See Pediatrics: Newborns, Infants, Children andPush needle set tip through the skin until tip rests

Adolescents, page 66]

against the bone. At least one black line on theconfirmation of adequate needle set length (the line

What if the Driver Seems to Be Losing
Power and Slows Down?

helps serve as a “depth gauge” of the soft tissue to

The most common cause of the driver slowing or

the bone). Engage driver trigger and apply gentle-

stalling is improper technique; specifically, applying

moderate, steady downward pressure until needle

too much downward pressure during insertion. The

set penetrates the bone. Once the needle set is atneedle set should always be inserted with gentle-

the desired depth, the trigger is released to avoid

moderate pressure, allowing the driver to “do thecontinual spinning. The hub of the needle should bework” and beveled needle set to cut through theclose to or flush with (but not pressed into) the skinbony cortex as it advances, using the minimal

catheter must be visible above the skin for

22

23

TECHNIQUE/TRAINING

amount of pressure required to keep the driver

Figure 3

advancing into the bone. If the driver is unavailable
or inoperable, the EZ-IO® Needle Set may beinserted manually without the driver as a back-up
insertion method. [See Manual Insertion Techniqueon this page]
If the condition of the driver slowing or stalling
persists despite proper use, please call Customer
Service at 866.479.8500 (outside U.S.:+1.866.479.8500). The drivers are equipped witha power indicator light that illuminates when thedriver trigger is deployed. This light illuminates
green when the battery has sufficient power andred when the driver needs to be replaced. Multiple
factors influence battery life including storage
conditions such as temperature extremes, frequency
of use, and age of driver. Refer to the driver IFU for
more information. [See EZ-IO® Driver and Training
Driver, page 44]

What is the Manual Insertion Technique
When a Driver is Unavailable or Inoperable?
Manual insertion of IO access is recommended only

Steps:
1.	 Push needle set tip through the skin until tip
rests against the bone. At least one black line on
the catheter must be visible above the skin for
confirmation of adequate needle set length.
2.	 Hold the needle set with the catheter hub andstylet as one piece (ensuring the stylet and hub
remain screwed together).
3.	 Rotate clockwise/counter-clockwise while applying gentle-moderate, steady downward pressure
without rocking the needle set. Allow rotationand pressure to penetrate the bone cortex, notexcessive force.
•pressure or resistance is felt as a “give” orwhen the driver is unavailable or inoperable. Use of
the driver optimizes tactile feedback and sensitivity.
Clinicians can more easily discern when the needle
set passes from the hard outer bone cortex into theless dense medullary space.1 The mechanized drivercreates a clean entry hole the size of the catheter.2
See Figure 3.

Pediatrics: Stop insertion when a change in“pop” indicating entry to medullary space.

•

Adult: Advance needle set approximately
1-2 cm after entry into medullary space
which is felt as a change in resistance; in theproximal humerus for most adults the needle
set should be advanced 2 cm or until hub isflush or against the skin.

4.	 Stabilize needle set hub and remove stylet.

TECHNIQUE/TRAINING

For additional information see www.teleflex.com/

epinephrine-free lidocaine). [See Pain Management

ezioeducation.

for IO Infusion, page 63] [See EZ-Connect® Extension
Set, page 46]

1Miller L, Philbeck T, Bolleter S, Garcia G. Tactile feedback
comparison of three types of intraosseous access devices forneedle insertion accuracy. Ann Emerg Med 2010;56(3):S133.TS

2

Teleflex internal study done in cadaveric bone.

How Should the EZ-IO® Catheter Be
Stabilized?
After insertion of the EZ-IO® Catheter, use the
EZ-Stabilizer® dressing to help secure the catheter
and help prevent accidental dislodgement. Remove
the stylet holding the catheter hub in place, place
EZ-Stabilizer® dressing over the hub, then attach
the primed EZ-Connect® Extension Set to the hub.
Firmly secure EZ-Connect® Extension Set by twisting
clockwise. If an EZ-Stabilizer® dressing is unavailable,
other methods should be used to secure the device.
Additionally, for the proximal humerus site, the arm
should be secured in an adducted position tominimize chance of dislodgement; and in pediatricpatients, a leg board or other securement method
may be needed to prevent dislodgement due tomovement. [Refer to EZ-Stabilizer® dressing
Directions for Use at www.teleflex.com]

Should the EZ-Connect® Be Primed with
Fluid Prior to Use?
Yes. Always prime the EZ-Connect® Extension Set
with fluid before attaching to the EZ-IO® Catheter
hub. The approximate volume of the EZ-Connect®
Extension Set is 1.0 mL. (Note: If the patient is
responsive to pain, consider priming the EZConnect® Extension Set with preservative-free andDoes the EZ-Connect® Extension Set Meet
Hospital Infection Control Standards?
The EZ-Connect® Extension Set uses the Robertsite®
Needleless Connector by Halkey-Roberts. The
connector valve satisfies all Centers for Disease Control
and Prevention (CDC) requirements for needlelessintravascular systems. For further specification
information see: http://www.halkeyroberts.com/
userfiles/files/Medical%20Miscellaneous/RNV%20
Book/RNV%20Book%202015.pdf (Accessed
02/08/2017) [See EZ-Connect® Extension Set, page 46]

What is the EZ-IO® Needle Set Made of?
The catheter and stylet are made of 304 stainlesssteel. The plastic hub is medical grade polycarbonate.
The EZ-IO® Needle Set is not made with natural
rubber latex.

Is a Syringe Flush Necessary after
IO Insertion?
Yes. It is essential to inject a syringe flush into the
IO space before attempting to infuse fluids throughthe IO catheter. A syringe flush helps clear the
marrow and fibrin from the medullary space, allowing
for effective infusion rates.
NO FLUSH = NO FLOW.
In pediatric patients, flush with 2-5 mL of normal
saline; in adult patients, flush with 5-10 mL of
normal saline.

24

25

TECHNIQUE/TRAININGDo NOT use extreme pressure for the flush,

to IO infusion, and infusing fluids and medications

especially in pediatric patients, as it may increase

under pressure (e.g. infusion pressure pump or

the risk of extravasation/infiltration and cause morepressure bag). Gravity alone will rarely generate

pain for the patient. [See Flow Rates and Infusion

adequate flow rates; the higher the pressure, theUnder Pressure, page 27]

faster the flow.EO In general, research shows thathigher flow rates are obtainable in the proximal

Is it Necessary to Flush the IO Line with
Saline after Infusing Medications Via the
IO Route?

humerus and sternal sites than tibial sites.4-6[See Flow Rates and Infusion Under Pressure,page 27]

Yes. As with an IV infusion, patency should be
confirmed and the IO line should be flushed before

and concentration. The volume of the EZ-Connect®

Does the Syringe Flush Have to Be RepeatedWith Prolonged Use? Will the IO Catheter
Become Occluded if Unused for a
Few Hours?

Extension Set is approximately 1.0 mL and should

IO access may be compromised if the line is not

be factored in for medication administration.

used for prolonged periods. Often, IO lines can be

and after infusion to ensure all prescribed medication
has entered the vascular space in the proper amountopened by an additional syringe flush. In an ongoing

What Flow Rates Can Be Achieved With
the EZ-IO® Device? How Can Flow Rates
Be Optimized?

clinical adult volunteer study, an infusion rate of
30 mL/hour per infusion pump has been sufficient tomaintain IO line patency for a period of 48 hours.7

In published literature, IO flow rates (delivered
under pressure) range from 200 mL/hr to 9,900(based on a human volunteer study) approximated

Can a Heparin Lock/Saline Lock Be Used
to Maintain Patency of an IO Line? What
Should Be Done if the Line Clots?

five liters per hour through the humerus and one

There is no data on the practice of using a heparin

liter per hour through the tibia; both with 300 mmHg

or saline lock solution with IO vascular access.

of pressure.4 A more recent volunteer study

Confirm IO catheter placement in the medullary

resulted in proximal humerus mean flow rates ofcavity. Attempt to administer a syringe flush to open

6,292 ± 3,277 mL/hr (n= 52); sternal flow rates werethe line. Depending on frequency of IO site access,

9,587± 2,706 mL/hr (n = 27).6 As with other vasculara repeat syringe flush may be necessary to re-openaccess lines, IO flow rates will vary among patientsthe line. Organizational policies and procedures

and anatomical sites.

should dictate whether instillation of medications

mL/hr.

1-6

A 2010 estimate for flow rates in adults

should be used to open an obstructed IO catheter.
Adequate flow rates are dependent on correct
insertion depth, performing a syringe flush prior

EO = Expert Opinion

TECHNIQUE/TRAINING

Can Another IO Catheter Be Placed in
the Same Bone Immediately Following a
Failed Insertion or Infusion?

Refer to company training materials and IFU for

No, this is a contraindication for use for the EZ-IO®
Needle Set. After a failed insertion (or once an IO

Does the Insertion Site Leak after EZ-IO®
Catheter Removal?

catheter is removed), another IO catheter placement

A small amount of bleeding may occur after EZ-IO®

should not be attempted in the same bone for 48

Catheter removal. Apply direct pressure to the site

hours. If multiple attempts are made in the samefor 1-2 minutes to control bleeding. More time may

bone, repeated penetration of the cortex will likely

be required for anticoagulated patients or patientsresult in infiltration or extravasation, which may leadwith coagulopathy.

proper removal technique.

to more serious complications (e.g. compartment
syndrome). An alternate site must be chosen.

Does the Insertion Site Require Special
Dressing or Care after Device Removal?

What is Proper EZ-IO® Catheter RemovalTechnique?

No special dressing is required after removal of the

To withdraw the catheter, remove the EZ-Connect®

appropriate. Post IO catheter removal, monitor the

Extension Set and EZ-Stabilizer dressing. Attach

involved limb for any signs of delayed presentationa Luer Lock syringe to the hub. Maintaining axialof symptoms of potential complications includingalignment, twist the syringe and catheter clockwise,

but not limited to fever, discoloration, swelling, pain

while pulling straight out. Do not rock or bend(with active or passive motion), paresthesias, skin

the catheter during removal. Dispose of all sharps

feeling cool or warm, pulses, firmness or taut feel toin a proper sharps container. Apply pressure asarea as compared to other limb.

®

EZ-IO® Catheter. A bandage or any clean dressing isneeded, dress the site. Refer to company training
materials and Instructions for Use (IFU) for proper

Discharge instructions should include teaching

removal technique.

patient/ family members to assess for and seek
immediate treatment for development of any of theWhat Can Be Done if the EZ-IO Catheter
Breaks Off the Hub or is Impossible to Remove by the Recommended Method?
®

above symptoms.

If the plastic hub breaks from the catheter, grasp

Can a Patient Ambulate With a Tibial IO
Catheter in Place?

the catheter with a hemostat, Kelly clamp, or similar

Ambulation should be discouraged until the tibial IO

medical tool using aseptic technique and rotate thecatheter is removed to reduce risk of dislodgement.

catheter while firmly pulling outward. If the catheter
cannot be visualized, a physician should be consulted.

26

27

FLOW RATES AND INFUSION UNDER PRESSURE

Are There any Exercise Restrictions after
EZ-IO® Catheter Removal?

adults (based on a human volunteer study)

No. There are generally no exercise restrictions

humerus and one liter per hour through the tibia;

after removal of an EZ-IO Catheter unless theboth with 300 mmHg of pressure.2 A more recent

physician otherwise instructs to limit activity.

volunteer study resulted in proximal humerus mean®

approximated five liters per hour through theflow rates of 6,292 ± 3,277 mL/hr (n = 52); sternal
1

Dubick MA, Holcomb JB. A review of intraosseous vascularaccess: current status and military application. Mil Med 2000;

2

165:552-9.

As with other vascular access lines, IO flow rates

Tan BKK, Chong S, Koh ZX, et al. EZ-IO® in the ED: anwill vary among patients and anatomical sites.

observational, prospective study comparing flow rates with

Flow rates are dependent on performing a syringe

proximal and distal tibia intraosseous access in adults. Am J

flush prior to IO infusion and infusing fluids andEmerg Med 2012; Early Online:1-4.TS
3

medications under pressure. Failure to perform a

Ong MEH, Chan YH, Oh JJ, Ngo AS-Y. An observational,
prospective study comparing tibial and humeral intraosseous

5

syringe flush is a common reason for lack of flow

access using the EZ-IO . Am J Emerg Med 2009;27:8-15.

and/or inadequate flow rates. Other factors affecting

Philbeck TE, Miller LJ, Montez D, Puga T. Hurts so good;

IO flow rates include bone structure, catheter

easing IO pain and pressure. JEMS 2010;35(9):58-69.TS

position within bone, types of fluids being infused,

Philbeck TE, Puga T, Montez DF, Miller LJ, Saussy J,

and specific patient characteristics.

®

4

flow rates were 9,587 ± 2,706 mL/hr (n = 27).6

TS

Davlantes C. Sternal flow rates and insertion success using a
multisite intraosseous device. Ann Emerg Med 2015;66(4):S48TS

6

http://dx.doi.org/10.1016/j.annemergmed.2015.07.167.

Infusing Under Pressure

Puga T, Montez D, Philbeck T, Davlantes C. Adequacy of

An IV pressure bag capable of generating 300 mmHg

intraosseous vascular access insertion sites for high-volume

pressure or a standard IV infusion pump is usually

fluid infusion. Crit Care Med 2016;44(12):143.TS
7

Davlantes C, Puga T, Montez D, Philbeck T, Miller L, DeNoia E.

required. To infuse fluids into the IO space one must48 hours dwell time for intraosseous access: A longer-term

first overcome the intrinsic resistance of the pressure

infusion using a temporary solution. Crit Care Med 2016;44

gradient between the IO space and the infusion(12):140.TS

system.7 Sufficient pressure and consistent flow rateusually cannot be attained by manually squeezing theFlow Rates and Infusion
Under Pressure
Flushing and Flow Rates
Described in published literature, IO flow rates

IV bag.EO

Pressure Pumps
Pressure is a rate-limiting factor in achieving
adequate flow rates in IO infusions; the higher thepressure, the greater the flow rate. Some electronic(delivered under pressure) range from 200 mL/hr
to 9,900 mL/hr.1- 6 A 2010 estimate for flow rates in

EO = Expert Opinion

FLOW RATES AND INFUSION UNDER PRESSURE

infusion pumps are designed to administer large

A preclinical study by Lairet resulted in twovolumes of fluid rapidly, but often work by measuring

instances of a distal extraosseal leak of unknown

volume rather than infusion pressure. Some rapid

cause (thought to be clinically insignificant) with

infusers (such as the Level 1 ) are set to deliver a

the use of the higher pressures (approximately

constant 300 mmHg of pressure and will deliver the

600 mmHg) of the power injector. However,volume achievable with that set pressure. Whensubsequent histological evaluations showed nopressure exceeds 300 mmHg most infusion pumps,

damage in the limbs that received power-infused

including rapid infusers, automatically shut off orcontrast media (under high pressure).9 Anotherdeliver the last rate achieved prior to the excessive

preclinical study conducted to examine thepressure. Therefore, these pumps may limit theimmediate effects of power injection of contrast

ability to deliver desired IO flow rates due to limits

media on the medullary cavity and marrow in

on infusion pressures. If adequate IO flow rates

mature swine found no histological difference

cannot be achieved with an infusion pump, a simple

between the limbs that received power injection

pressure bag may be used.

and those that did not, when examined®

8

post-infusion.10

Maximum Pressures for Infusion
In clinical practice, a maximum of 300 mmHg isHigh Pressure Infusions /Power Injection

generally used to facilitate flow. Therefore, there is

The EZ-IO® Catheter has been shown to withstand up

no known “maximum” infusion pressure. There are

to 325 psi (approximately 16,800 mmHg) without

several considerations:catheter leakage or rupture in an engineering

1.	 Equipment limits. Most pressure bag infusion

study.11 In another study, the EZ-Connect®

systems will not exceed 300 mmHg.
2.	 Flow rates. Pressure and flow rates are directly

Extension Set did not withstand this level of pressure
and should not be used for high pressure infusion/correlated: greater applied pressure will generally

power injection.12 The EZ-IO® Catheter has not been

result in higher flow rates.2

rated for power infusion.

3.	 Pain management. Pressure and infusion pain
are directly correlated; therefore, higher

1

access: current status and military application. Mil Med

pressures will generally result in higher pain in
the conscious patient, and a greater need for

2000;165:552-9.
2pain management.2
4.	 Potential for bone damage. It is unknown
whether higher infusion pressures have potential
for medullary damage.

Dubick MA, Holcomb JB. A review of intraosseous vascular

Philbeck TE, Miller LJ, Montez D, Puga T. Hurts so good;easing IO pain and pressure. JEMS 2010;35(9):58-69.TS

3

Tan BKK, Chong S, Koh ZX, et al. EZ-IO® in the ED: anobservational, prospective study comparing flow rates withproximal and distal tibia intraosseous access in adults.
Am J Emerg Med 2012;Early Online:1-4.TS

28

29

SELECTION OF APPROPRIATE INSERTION SITE AND NEEDLE SET

4

Ong MEH, Chan YH, Oh JJ, Ngo AS-Y. An observational,
prospective study comparing tibial and humeral intraosseousaccess using the EZ-IO . Am J Emerg Med 2009;27:8-15.
®

5

TS

Philbeck TE, Puga T, Montez DF, Miller LJ, Saussy J, Davlantes C.
Sternal flow rates and insertion success using a multisite

Selection of Appropriate
Insertion Site and Needle
Setintraosseous device. Ann Emerg Med 2015;66(4):S48TS
http://dx.doi.org/10.1016/j.annemergmed.2015.07.167.
6

Puga T, Montez D, Philbeck T, Davlantes C. Adequacy of
intraosseous vascular access insertion sites for high-volume

8

locate anatomical landmarks, and clinical judgment

Paxton JH. Intraosseous vascular access: A review. Trauma

and experience. Site selection is also dependent on

2012;14(3):195-232. doi:10.1177/1460408611430175.

the absence of contraindications, accessibility of theLevel 1® H-1200 Fast Flow Fluid Warmer with Integrated Air

site, and the ability to monitor and secure the site.

Detector/Clamp product specifications available at:https://www.smiths-medical.com/products/temperature-

Comparative studies in the literature may also help

management/blood-and-fluid-warming-systems/fast-flow-fluid-

guide decision-making. Several clinical andwarming-trauma/level-1-h1200-fast-flow-fluid-warmer-with-preclinical studies suggest the humerus may be a

integrated-air-detectorclamp (accessed 10/26/2016).
9

anatomy, presenting condition; as well as ability to

fluid infusion. Crit Care Med 2016;44(12):143.

TS

7

IO site selection depends on patient age, size,

Lairet JR, Bebarta V, Lairet K et al. A comparison of proximal
tibia, proximal humerus, and distal femur infusion rates under

superior extremity access site for flow rates, drugdelivery, and management of infusion pain, althoughhigh pressure (> 300 mmHg) using the EZ-IO intraosseous

Ong’s clinical study reported no significant difference

device on an adult swine (sus scrofa) model. Prehosp Emergin flow rates between the tibia and humerus.1-5®

Care 2011;15(1):117.
10 Puga T, Hanes MA, Miller LJ, Montez DF, Davlantes C,
Philbeck TE, Saussy J. Intramedullary effects of power-infusedcontrast by intraosseous access. Ann Emerg Med 2015;66(4)Regardless of IO site selected the clinical patient
scenario, clinician experience and comfort levelmust be taken into consideration.

Supp:95-96.TS doi: http://dx.doi.org/10.1016/j.annemergmed.
2015.07.299.
11 Internal Report. ISO 594-2 and high pressure liquid leakage
testing for the Vidacare* Corporation EZ-IO® Needles. Report

Abdominal/Lower Extremity Trauma: The preferred
IO sites for fluid and drug administration in patients

number 1105192. DDL. June 15, 2011. *Vidacare was acquiredwith lower extremity, abdominal or pelvic injuries

by Teleflex in 2013.

are the proximal humerus and sternum.EO Fluids

12 Internal Report by Teleflex. Pre-clinical study and bench testing

given rapidly reach the central circulation via theto determine the utility of the EZ-IO® Vascular Access Systemsuperior vena cava, thereby bypassing pelvic andfor delivering contrast dye using a power injector forcomputerized tomography studies. June 2010/April 2014.TS

abdominal vasculature.2,4,6 In cases of major trauma
to a lower extremity with suspected vascular injury,
IO access should not be attempted in that extremity.

EO = Expert Opinion

SELECTION OF APPROPRIATE INSERTION SITE AND NEEDLE SET

EZ-IO® Needle Set Selection

Kehrl et al. recently published a study using

Clinical judgment should always be used to determine

ultrasound to measure soft tissue depth at theappropriate needle set selection based on patient

proximal tibia (PT), distal tibia, and proximal

anatomy, weight, tissue depth, and presenting

humerus (PH) in 75 obese patients with a BMI

condition. The EZ-IO Needle Set is 15 gauge and isgreater than 30; also assessing whether the tibial

available in three different lengths with associatedtuberosity (TT) was palpable or not palpable inweight ranges to serve as a general guide: 15 mm

this group. In 70 patients with an average BMI of(pink hub, 3-39 kg weight range), 25 mm (blue hub,

45.7, the TT was palpable; and non-palpable in five

3 kg or over), and 45 mm (yellow hub, 40 kg or overpatients with an average BMI of 67.2. The soft tissue

and/or excessive soft tissue). Tissue depth overdepth exceeded 20 mm at all three anatomic IO sites

the insertion site should always be assessed whenin all patients with a non-palpable TT. While authors

determining the most appropriate needle set length

found BMI to be moderately predictive of soft tissue

and prior to every insertion using the EZ-IO Device.

depth, it did not correlate for the higher BMI nor the*Please note that EZ-IO needles with red hubs

proximal humerus. The findings suggested a 25 mm

are non-sterile and for non-clinical training

needle set would be adequate in the PT for most

purposes only.

obese patients with a palpable TT, and the 45 mm

®

®

®

needle set should always be used for the PHIO site.8
The EZ-IO® Catheter is marked with black lines. If
the EZ-IO® Needle Set is inserted through the soft

In 2012 Rush et al. reported on a retrospective study

tissue and does not reach the bone, or at least one

in which 50 consecutive MRI images of the humerus

black mark is visible above the skin when the needle

were evaluated for the purpose of determining the

tip is touching the bone, but before power is applied

optimal needle length necessary for successful

to the driver, a longer needle set or alternate site

proximal humerus IO insertion. Results showed theshould be chosen prior to penetration of the cortex.

cortical thickness was 4 mm in all cases and that an

If there is any chance the cortex has been breached,

IO needle length ranging between 40-50 mm should

you must choose another target bone to decrease

be used via the anterior approach.9

extravasation risk. Clinical experience with thedevice will ultimately present a more rapid approach

Adults: Generally the 25 mm EZ-IO® Needle Set

to needle set selection, but the black depth line willis the correct length for tibial access. The 45 mm

help to establish if the needle set is long enough andneedle set should be considered for the proximal

assist in decisions about which needle set length ishumerus site in most adults and/or any site whenappropriate for the patient.

excessive tissue overlies the insertion site.
Visualization of at least one black line on thecatheter, above the skin, when the needle tip

30

31

SELECTION OF APPROPRIATE INSERTION SITE AND NEEDLE SET

is touching bone must still be done prior totraining and technique, device choice, andevery insertion.

consistent reassessments.

Pediatrics: The following is a general guide forneedle set selection in pediatric patients (3-39 kg).

1

Philbeck TE, Miller LJ, Montez D, Puga T. Hurts so good;easing IO pain and pressure. JEMS 2010;35(9):58-69.TS

2

Hoskins SL, Kramer GC, Stephens CT, Zachariah BS. Efficacy ofNote: visualization of at least one black line on

epinephrine delivery via the intraosseous humeral head routethe catheter, above the skin, when the needle tip

during CPR. Circulation 2006;114:II_1204.TS

is touching bone must still be done prior to every

3

Hoskins SL, Zachariah BS, Copper N, Kramer GC. Comparisonof intraosseous proximal humerus and sternal routes for drug

insertion:delivery during CPR. Circulation 2007;116:II_933.TS

15 mm: Proximal and distal tibia insertion in

4

neonates and small infants.

Montez DF, Puga T, Miller L, et al. Intraosseous infusions fromthe proximal humerus reach the heart in less than threeseconds in human volunteers. Ann Emerg Med 2015;66(4):S47.TS

25 mm: Distal femur insertion in neonates andhttp://dx.doi.org/10.1016/j.annemergmed.2015.07.165.

small infants or proximal humerus, distal femur,
proximal, and distal tibia insertion in children.

5

Ong ME, Chan YH, Oh HH, Ngo AS. An observational
prospective study comparing tibial and humeral intraosseousaccess using the EZ-IO®. Am J Emerg Med 2009;27:8-15.TS

A recent post-mortem study on pediatric patients

6

that received IO vascular access with a number ofdevices demonstrated a rate of 76.7% proper

option for IO access. JEMS 2010;35(8):52-59.
7

bone, and one placed into the knee joint.10 Pifko

Miller L, Philbeck T, Bolleter S, Garcia G. Tactile feedback
comparison of three types of intraosseous access devices forplacement with 23 insertions into the soft tissue ofthe leg, eight insertions through and through the

Kovar J, Gillum L. Alternate route: the humerus bone – a viable

needle insertion accuracy. Ann Emerg Med 2010;56(3):S133.TS
8

Kehrl T, Becker BA, Simmons DE, Broderick EK, Jones RA.
Intraosseous access in the obese patient: Assessing the needpublished a small retrospective clinical study thatfor extended needle length. Am J Emerg Med 2016;doi:10.1016/

evaluated attempts to establish intraosseous

j.ajem.2016.06.055.

vascular access in pediatric patients using a manual
device and the EZ-IO® Device. The EZ-IO® Device
had a higher first attempt success rate comparedto the manual device with a 56% success rate formanual and 69% success for the EZ-IO Device®

overall. For the subset of smaller patients weighing≤ 8 kg there was a 52% success for manual and9

Rush S, Bremer J, Foresto C, Rubin AM, Anderson PI. A
magnetic resonance imaging study to define optimal needle
length for humeral head IO devices. J Spec Oper Med 2012;12(2):77-82.

10 Jawad N, Brown K, Sebire NJ, Arthurs OJ. Accuracy of
paediatric intraosseous needle placement from post mortem
imaging. JOFRI 2015; http://dx.doi.org/10.1016/j.jofri.2015.
10.003.
11 Pifko EL, Busch C, Price A, et al. An observational review of

75% success for the EZ-IO® Device. Two patients

pediatric intraosseous needle placement in the pediatrichad transient limb swelling after the EZ-IO

emergency department. Ann Emerg Med 2015;66(4s):S87.

®

Catheter insertion.11 The reports of both Pifko
and Jawad reinforce the importance of proper

STERNAL SITE

Sternal Sitedescribes a comparative study with the proximal
humerus as having superior flow rates and less pain
when compared with the tibia.5-9 One of the firstFirst described by Tocantins in 1940, the sternum
was among the first bones used for IO access.1 This
site option is important when other sites arecontraindicated, as with injuries sustained due toexplosives when the manubrium of the sternum
may be the most accessible uninjured site or intactical medicine due to body armor. The EZ-IO®
T.A.L.O.N. is indicated for military and tactical™

team use. The EZ-IO® T.A.L.O.N.™ provides sevensite options with access to the sternum using asternal locator; and using the needle set without
the locator and manual insertion technique, gains
access to the proximal humerus, proximal tibia, anddistal tibia. In a clinical volunteer study Philbeck et
al. described mean sternal flow rates ranging from
1,130 ± 692 mL/hr with gravity and no pressure to
5,327 ± 1,724 mL/hr with 300 mmHg of pressure.2
A more recent human volunteer study resulted insternal flow rates when using the EZ-IO® T.A.L.O.N.™
and 300 mmHg of pressure of 9,587± 2,706 mL/hr(n = 27).3 Cadaveric studies using the FAST1® (PYNG
Medical*, Richmond, Canada) have reported a mean

descriptions of humeral IO access use was publishedin 2009 in the Journal of Trauma. The study comparedvarious vascular access methods including proximal
humerus IO, peripheral venous access, and central
venous access routes. The study concluded thataccess into the proximal humerus was significantly
faster than the other two routes.10 Three prehospitalstudies have evaluated use of the proximal humerus
for cardiac arrest. The most recent retrospective
study by Ross 2016 reported on 2,600 cases of IO
access for cardiac arrest with a total first passsuccess rate of 95.6% and the majority placedin the humerus (86.2% placed in the proximal
humerus and 13.8% in the proximal tibia). The
humerus had a significantly lower complication rate
when compared to the tibia 8.2% versus 12.6%(p < 0.01).11 Two prehospital studies by Reades
et al. found the proximal humerus to have a lower
success rate than the proximal tibia.12,13 Lack ofstabilization, as described in this article, may havecontributed to dislodgements and the lower
success rates.

sternal flow rate of 93.7 ± 37.9 mL/min.4 (*PYNG
Medical was acquired by Teleflex on April 3, 2017)

Figure 4
Pull

1

EZ-IO T.A.L.O.N.
Sternal Locator

humerus as an efficacious IO site for insertion
success, flow rates, drug delivery, andmanagement of infusion pain. Philbeck 2010

2

application area

For adult patients, studies support the proximal

™

Pull

Proximal Humerus

®

32

33

PROXIMAL HUMERUS

Wampler et al. reported a success rate of 94%. EMS

A preclinical study in 2006 using epinephrine

providers participated in a standardized training

demonstrated that humeral IO access generated

program provided by EZ-IO Clinician Educators

higher mean arterial pressures than central venous

guiding proper landmarking, needle selection, andaccess. The authors concluded IO humeral head

the importance of catheter and limb securement

delivery of epinephrine during cardiac arrest is asprior to the start of the study.

effective as intravenous infusion.15 A 2007 study in®

6swine compared the proximal humerus and sternalroutes during CPR, and concluded the humerus
Figure 5route is an effective alternative to IO sternal
Manual Handle
with stylet

Drawing of EZ-IO®

delivery during CPR.16

T.A.L.O.N.™ Sternal Locator
Cannulaover insertion site

Locator Hub(the manubrium)

Adhesive Tape

Flow Rates
Clinical and healthy volunteer studies have evaluatedflow rates using various sites and pressure methods.
With the exception of one study by Ong et al.,costalcartilage

Manubrium
clavicular
articulation

Pectoralis
majorevidence to date supports the proximal humerus
and sternum as the optimal sites when maximum
flow rates are desired.2,3,8,9

Figure 6
EZ-IO® T.A.L.O.N.™

Pain Management

sternal insertion

A series of studies in healthy volunteers demonstrated

with fluid infusion

reasonable relief of IO infusion pain with initialand pressure bagpreservative-free and epinephrine-free lidocaine(safe for intravenous use) dosages of 40 mg, anda subsequent 20 mg dose after flushing.9 For IO
infusions in the proximal humerus, pain relief wassustained for 90 minutes without re-dosing. The
proximal humerus may be the preferred site forDrug Delivery
In a study with healthy adult volunteers, contrast
media injected through the proximal humerus site,and captured under fluoroscopy as it entered theright atrium took 2.42 seconds (mean time).14

conscious patients due to less infusion pain andthe ability to better manage pain as compared to theproximal tibia. A volunteer study done in June 2016
administering 2% preservative-free and epinephrinefree lidocaine compared doses of 40 mg followed by
a flush followed by placebo or an additional 20 mg

EZ-IO® DEVICE PROXIMAL HUMERUS IDENTIFICATION AND INSERTION TECHNIQUE

dose. This study indicated the second dose ofin pediatric patients, taking into account the

20 mg may be optional in the proximal humerus.

17

weight of the patient, and the overlaying
tissue depth.

Lidocaine and appropriate dosages must be

2.	 Site Identification. Identification of the correct

prescribed by a qualified prescriber. Moreinsertion site is a critical aspect of accessing theinformation on pain management is available

proximal humerus. The surgical neck and theat www.eziocomfort.com.

greater tubercle of the proximal humerus are
key landmarks.

Can the Proximal Humerus Site Be Used in
the Perioperative Setting?
When indicated for use in the perioperative setting,the EZ-IO® Catheter should be inserted into theproximal humerus as described in the instructions
for use. After placement, the patient’s arm can berepositioned as needed but extreme care should betaken to ensure the arm is not abducted more than
45-degrees from the side of the body. Specific

EZ-IO® Device Proximal
Humerus Identification
and Insertion Technique
Identify the Proximal Humerus:

training is available for proximal humerus insertionsite identification including literature with stepby-step instructions, anatomic visuals, written
training materials, and video demonstrations. This
information is available at: http://www.teleflex.com/

Figure 7
Place the patient’s handover the abdomen (if unable
to place as pictured ensure
the elbow is adducted andhumerus internally rotated).

ezioeducation.
When accessing the humerus site, the following
should be considered:
1.	 Needle Set Selection. The proximal humerus iscovered by layers of muscle and skin. Therefore,
the longer EZ-IO® 45 mm Needle Set (yellowhub) is recommended for this site in most adultpatients or adolescents 40 kg or over. Clinicaljudgment should be used for needle set selection

Figure 8
Place your palm on thepatient’s shoulder anteriorly.
• The area that feels like a“ball” under your palm isthe general target area.
• You should be able to feel
this ball, even on obese
patients, by pushing deeply.

34

35

EZ-IO® DEVICE PROXIMAL HUMERUS IDENTIFICATION AND INSERTION TECHNIQUE

Figure 9
Place the ulnar aspectof one hand verticallyover the axilla.

Figure 13
The insertion site is on
the most prominent aspectof the greater tubercle,
1 to 2 cm above the surgicalneck and lateral to theintertubercular groove or
sulcus (also known as thebicipital groove).

Insertion:
Figure 10
Place the ulnar aspect of
the opposite hand along
the midline of the upper
arm laterally.

Figure 11
Place your thumbs
together over the arm.
• This identifies the verticalline of insertion on theproximal humerus.

Figure 12
Palpate deeply as you climb up the
humerus to the surgical neck.
• It will feel like a golf ball ona tee – the spot where the “ball”
meets the “tee” is the surgical neck.
• The insertion site is on the mostprominent aspect of the greatertubercle, 1 to 2 cm above thesurgical neck.

• Prepare the site by using antiseptic solution per
institutional protocol using a clean, “no touch”
technique.
• Remove the needle set cap.
• Once the insertion site is determined as describedabove, insert the needle set tip through the skinapproximately 45-degrees anterior to the horizontal
plane and aim the needle set downward approximately
45-degrees. Some find it helpful to think of aiming
toward the inferolateral border of the scapula. See
Figure 14.
• Push the needle set tip through the skin until the tip
rests against the bone.
IMPORTANT: At least one black line from the hub
must be visible above the skin for confirmation ofadequate needle length (always check this before pressing
the trigger).
• Gently drill into the humerus 2 cm or until the hub
reaches the skin in an adult. Stop when you feel the“pop” or “give” in infants and children. Avoid recoilby actively releasing the trigger when you feel theneedle set enter the medullary space – do NOT pullback on the driver when releasing the trigger.

Figure 14
Insert the needle set tip over
the anterolateral part of thearm, 1-2 cm above the surgicalneck, then aim the needle set
downward at approximately
a 45-degree angle, aiming
toward the inferolateral borderof the scapula.

EZ-IO® DEVICE PROXIMAL HUMERUS IDENTIFICATION AND INSERTION TECHNIQUE

Figure 19

Figure 15
Hold the hub in place
and pull the driverstraight off.

Aspirate for blood/bonemarrow (Second confirmationof placement. The inability
to withdraw/aspirate bloodfrom the catheter hub does
not mean the insertion was
unsuccessful. Consider
attempting to aspirate after
the flush.).
• Flush the IO catheter with normal saline (5–10 mL adults;
2–5 mL for infants and small children).
• Connect fluids if ordered; infusion may need to bepressurized to achieve desired rate. See Figure 20.
• Secure the arm in place across the abdomen, or in
adducted position (with the patient’s arm at his /her side).
Monitor infusion, site and limb frequently.

Figure 16• Continue to hold the hub while
twisting the stylet off the hubwith counterclockwise
rotations. The needle should
feel firmly seated in the bone(first confirmation ofplacement).
• Place the stylet in a sharps
container.

Figure 20

Figure 17
Place the EZ-Stabilizer®
dressing over the hub.

1

Tocantins LM, O’Neill JF. Infusion of blood and other fluids into
the circulation via the bone marrow. Proc Soc Exp Biol Med
1940;45(3):782-3.

2

Sternal flow rates and insertion success using a multisite

Figure 18• Attach a primed EZ-Connect®
Extension Set to thehub, firmly secure by
twisting clockwise.
• Pull the tabs off the
EZ-Stabilizer® dressing
to expose the adhesive,
apply to the skin.

Philbeck TE, Puga T, Montez DF, Miller LJ, Saussy J, Davlantes C.
intraosseous device. Ann Emerg Med 2015;66(4s):S48TS
http://dx.doi.org/10.1016/j.annemergmed.2015.07.167.

3

Puga T, Montez D, Philbeck T, Davlantes C. Adequacy of
intraosseous vascular access insertion sites for high-volume
fluid infusion. Crit Care Med 2016;44(12):143.TS

4

Pasley J, Miller CHT, DuBose J, et al. Intraosseous infusion rates
under high pressure: a cadaveric comparison of anatomic sites.
J Trauma Acute Care Surg 2015;78(2):295-9. doi:10.1097/
TA.0000000000000516.

36

37

PROXIMAL TIBIA

5

Kovar J, Gillum L. Alternate route: the humerus bone – a viableoption for IO access. JEMS 2010;35(8):52-9.

6

Wampler D, Schwartz D, Shumaker J, Bolleter S, Beckett R,

17 Montez D, Puga T, Davlantes C, Philbeck T. IO Infusion Pain
Mitigation in the Sternum and Proximal Humerus: Establishinga Regimen. Crit Care Med 2016;44(12):154.TS

Manifold C. Paramedics successfully perform humeral EZ-IO®
intraosseous access in adult out-of-hospital cardiac arrest
patients. Am J Emerg Med 2012;30:1095-9. doi:10.1016/j.ajem.

Proximal Tibia

2011.07.010 TS
7

Miller L, Philbeck T, Montez D, Puga T. A two-phase study of
Ann Emerg Med 2010;56(3):S151.

Proximal Tibia Insertion Site Identification –Adults /Adolescents /Larger Children

Ong MEH, Chan YH, Oh JJ, Ngo AS-Y. An observational,

Extend the leg. Insertion site is approximately

prospective study comparing tibial and humeral intraosseous

2 cm medial to the tibial tuberosity, or approximately

access using the EZ-IO.® Am J Emerg Med 2009;27:8-15.TS

3 cm below the patella and approximately 2 cm

Philbeck TE, Miller LJ, Montez D, Puga T. Hurts so good;

medial, along the flat aspect of the tibia.

fluid administration measurement during intraosseous infusion.
TS

8

9

easing IO pain and pressure. JEMS 2010;35(9):58-69.TS

See Figure 21.

10 Paxton JH, Knuth TE, Klausner HA. Proximal humerus
intraosseous infusion: a preferred emergency venous access.
J Trauma 2009;67(3):606-11.TS
11 Ross EM, Mapp J, Kharod CU. Time to epinephrine in out-of-

Figure 21
Proximal tibia insertion site-

hospital cardiac arrest: A retrospective analysis of intraosseous

Adults/Adolescents/

versus intravenous access. Ann Emerg Med 2016;68(4s):S61.

Larger Children

12 Reades R, Studneck J, Garrett J, Vandeventer S, Blackwell T.
Comparison of first-attempt success between tibial and humeral
intraosseous insertions during out-of-hospital cardiac arrest.
Prehosp Emerg Care 2011;15(2):278-81. doi:10.31 09/
10903127.2010.545479.
13 Reades R, Studnek JR, Vandeventer S, Garrett J. Intraosseous
versus intravenous vascular access during out-of-hospital
cardiac arrest: a randomized controlled trial. Ann Emerg Med

Proximal Tibia Insertion Site Identification –2011;58(6):509-16. doi:10.1016/j.annemergmed.2011.07.020.

Neonates /Infants /Children

14 Montez DF, Puga T, Miller L, et al. Intraosseous infusions from

Neonates, infants, and small children: Extend thethe proximal humerus reach the heart in less than 3 seconds inleg. Insertion site is approximately 1 cm medial tohuman volunteers. Ann Emerg Med 2015;66(4):S47.TS
http://dx.doi.org/10.1016/j.annemergmed.2015.07.165.
15 Hoskins SL, Kramer GC, Stephens CT, Zachariah BS. Efficacy of

the tibial tuberosity, or (if the tibial tuberosity cannot
be palpated) approximately 1 cm medial to the tibial

epinephrine delivery via the intraosseous humeral head route

tuberosity, or just below the inferior border of theduring CPR. Circulation 2006;114:II_1204.TS

patella (approximately 1 cm) and slightly medial

16 Hoskins SL, Zachariah BS, Copper N, Kramer GC. Comparisonof intraosseous proximal humerus and sternal routes for drugdelivery during CPR. Circulation 2007;116:II_933.TS(approximately 1 cm) along the flat aspect of thetibia. Pinch the tibia between your fingers to identify

PROXIMAL TIBIA

the medial and lateral borders, and insert in the

medullary space (felt as a loss of resistance)

center of the bone.

or until the needle set hub is close to the skin

See Figure 22.

in adult patients.
Infants and small children: Gently drill,
immediately stop advancing and release the

Figure 22
Proximal tibia

Growth Plate

insertion siteNeonates/Infants/
Childrentrigger when you feel the “pop” or “give” asthe needle set enters the medullary space.
– Do NOT pull/jerk back (recoil) on the driverwhen releasing the trigger.
7.	 Hold the hub in place and pull the driverstraight off needle set.
8.	 Continue to hold the hub while twisting the stylet
off the hub with counterclockwise rotations.
9.	 The catheter should feel firmly seated in thebone (first confirmation of placement).
– Place the stylet in a sharps container.
10.	 Place the EZ-Stabilizer® dressing over the hub.

EZ-IO® Device Proximal Tibia
Insertion Technique:
1.	 Prepare the site with antiseptic as per
institutional protocol.
– Use a clean “no touch” technique.

11.	 Attach a primed EZ-Connect® Extension Set tothe hub, firmly secure by twisting clockwise.
12.	 Pull the tabs off the EZ-Stabilizer® dressing toexpose the adhesive, apply to the skin.
13.	 Aspirate for blood/ bone marrow (Second

2.	 Remove the needle set cap.

confirmation of placement. The inability to

3.	 Stabilize the extremity.

withdraw/aspirate blood from the catheter hub

4.	 Aim the needle set tip at a 90-degree angle todoes not mean the insertion was unsuccessful.

the flat surface of the bone.
5.	 Push the needle tip through the skin until the
tip rests against the bone.
IMPORTANT: At least one black line on theConsider attempting to aspirate after the flush.).
14.	 Flush the IO catheter with normal saline (5-10mL adults; 2-5 mL for infants and small children).
15.	 Connect fluids if ordered, infusion may need tocatheter must be visible above the skin for

be pressurized to achieve desired rate.

confirmation of adequate needle set length

16.	 Monitor infusion, site, and limb frequently.

(check for this before pressing the trigger).
6.	 Gently drill, advancing the needle set
approximately 1-2 cm after entry into the

38

39

DISTAL TIBIA

Distal Tibia

Figure 24
Distal tibia insertion site-

Distal Tibia Insertion Site Identification –Adults /Adolescents /Larger Children

Neonates/Infants/Children

Insertion site is located approximately 3 cm proximal
to the most prominent aspect of the medial malleolus.
Palpate the anterior and posterior borders of thetibia to assure that your insertion site is in the flat
center of the bone and 90-degrees (orperpendicular) to the surface of the bone.

EZ-IO® Device Distal Tibia
Insertion Technique:

See Figure 23.

Figure 23
Distal tibia insertion

Tibia

Fibula

1.	 Prepare the site with antiseptic as per
institutional protocol.	

site-Adults/Adolescents/– Use a clean “no touch” technique.

Larger Children

2.	 Remove the needle set cap.
Talus

Medialmalleolus

3.	 Stabilize the extremity.
4.	 Aim the needle set tip at a 90-degree angle tothe flat surface of the bone.
5.	 Push the needle tip through the skin until the
tip rests against the bone.
IMPORTANT: At least one black line on thecatheter must be visible above the skin for
confirmation of adequate needle set length(check for this before pressing the trigger).
6.	 Gently drill, advancing the needle set

Distal Tibia Insertion Site Identification –Neonates /Infants /Children

approximately 1-2 cm after entry into theInsertion site is located approximately 1-2 cm

until the needle set hub is close to the skinproximal to the most prominent aspect of the medialin adult patients.	

malleolus. Palpate the anterior and posterior borders

Infants and small children: Gently drill,of the tibia to assure that your insertion site is in theimmediately stop advancing and release theflat center of the bone and 90-degrees to the surface

trigger when you feel the “pop” or “give” asof the bone. See Figure 24.

the needle set enters the medullary space.

medullary space (felt as a loss of resistance) orDISTAL FEMUR– Do NOT pull/jerk back (recoil) on the driverwhen releasing the trigger.
7.	 Hold the hub in place and pull the driverof the patella (maximum 1-2 cm) and approximately
1-2 cm medial to the midline.
See Figure 25.

straight off needle set.
8.	 Continue to hold the hub while twisting the stylet
off the hub with counterclockwise rotations.
9.	 The catheter should feel firmly seated in the

Figure 25
Distal femur insertion siteNeonates/Infants/Children

bone (first confirmation of placement).
– Place the stylet in a sharps container.
Growth Plate

10.	 Place the EZ-Stabilizer® dressing over the hub.
11.	 Attach a primed EZ-Connect® Extension Set tothe hub, firmly secure by twisting clockwise.
12.	 Pull the tabs off the EZ-Stabilizer® dressing toexpose the adhesive, apply to the skin.
13.	 Aspirate for blood/ bone marrow (Second
confirmation of placement. The inability towithdraw/aspirate blood from the catheter hub
does not mean the insertion was unsuccessful.
Consider attempting to aspirate after the flush.).
14.	 Flush the IO catheter with normal saline (5-10mL adults; 2-5 mL for infants and small children).
15.	 Connect fluids if ordered, infusion may need to
be pressurized to achieve desired rate.
16.	 Monitor infusion, site, and limb frequently.

Distal Femur
The EZ-IO Device distal femur site is indicated for®

pediatric patients.

EZ-IO® Device Distal Femur
Insertion Technique:
1.	 Prepare the site with antiseptic as per
institutional protocol.
– Use a clean “no touch” technique.
2.	 Remove the needle set cap.
3.	 Stabilize the extremity and secure site with leg
outstretched to ensure knee does not bend (toavoid dislodgement after insertion).
4.	 Aim the needle set tip at a 90-degree angle tothe center of the bone.
5.	 Push the needle tip through the skin until the
tip rests against the bone.
IMPORTANT: At least one black line on the

Distal Femur Insertion Site Identification –Neonates /Infants /Children

catheter must be visible above the skin for

Secure site with leg outstretched to ensure knee

(check for this before pressing the trigger).

confirmation of adequate needle set length

does not bend. Identify the patella by palpation. The

6.	 Gently drill, immediately stop advancing andinsertion site is just proximal to the superior borderrelease the trigger when you feel the “pop” or

40

41

CARE AND MAINTENANCE OF THE EZ-IO® CATHETER“give” as the needle set enters themaintaining catheter patency, monitoring the

medullary space.

insertion site and limb for signs of extravasation /– Do NOT pull/jerk back (recoil) on the driverinfitration, or other abnormalities and appropriate
device stabilization and removal. The EZ-IO® Device

when releasing the trigger.
7.	 Hold the hub in place and pull the driveris indicated to remain in place for up to 24 hours in
the U.S. and for up to 72 hours in the EU.

straight off needle set.
8.	 Continue to hold the hub while twisting the stylet
off the hub with counterclockwise rotations.

Confirming EZ-IO® Catheter Placement

9.	 The catheter should feel firmly seated in the

Prior to administration of medications or fluids,bone (first confirmation of placement).

confirm EZ-IO® Catheter placement with the– Place the stylet in a sharps container.

following methods:

10.	 Place the EZ-Stabilizer dressing over the hub.
®

•Ability to aspirate blood or marrow (an inability

11.	 Attach a primed EZ-Connect Extension Set toto aspirate is sometimes described after initial

the hub, firmly secure by twisting clockwise.

IO catheter insertion). The inability to withdraw/

12.	 Pull the tabs off the EZ-Stabilizer dressing toaspirate blood from the catheter hub does not®

®

expose the adhesive, apply to the skin.

mean the insertion was unsuccessful.

13.	 Aspirate for blood/ bone marrow (Second
confirmation of placement. The inability towithdraw/aspirate blood from the catheter hub

Consider attempting to aspirate after the flush.

••

Stability of catheter
Adequate flow rate

does not mean the insertion was unsuccessful.
Consider attempting to aspirate after the flush.).
14.	 Flush the IO catheter with normal saline (2-5
mL for infants and small children).
15.	 Connect fluids if ordered, infusion may need to
be pressurized to achieve desired rate.
16.	 Monitor infusion, site, and limb frequently.

EZ-IO® Catheter Patency
Depending on the duration of IO site access andinfusion rate, a repeat syringe flush may benecessary to reopen the line. Refer to organizational
policies and procedures to determine whether
instillation of medications should be used to open
an occluded IO catheter. One adult volunteer study

Care and Maintenance of
the EZ-IO® Catheter

has demonstrated that a slow continuous infusion
rate of 30 mL/hr maintained patency for 40 hours.1

Care and maintenance of the EZ-IO Catheter isPain Management in Conscious Patients(Responsive to Pain)similar to other venous access routes: confirming

The pain associated with IO insertion is variable,

placement prior to medication administration,

whereas pain associated with IO infusion under®

CARE AND MAINTENANCE OF THE EZ-IO® CATHETER

pressure is often severe.2 Two percent (2%)*

Lidocaine and appropriate dosages must be

intravenous, preservative-free and epinephrine-freeprescribed by a physician or qualified prescriber.

lidocaine has been shown to be effective in limiting[See Pain Management for IO Infusion, page 63]

or alleviating IO infusion pain. Duration of theanesthetic effect will vary among patients. Repeat
doses of lidocaine may be necessary to maintain

The use of any medication, including lidocaine, given IV or IO
is the responsibility of the treating physician, medical director
or qualified prescriber and not an official recommendation ofanesthetic effect. Consider systemic analgesia for

Teleflex Incorporated and its subsidiaries. Teleflex is not thepatients as needed.

manufacturer of lidocaine, and the user should be familiar with

3,4

the manufacturer’s instructions or directions for use for all
indications, side-effects, contraindications, precautions and* 2% preservative-free and epinephrine-free lidocaine may not be

warnings of lidocaine. Teleflex disclaims all liability for theavailable globally; refer to total dose in milligrams.

use, application or interpretation of the use of this informationin the medical treatment of any patient. Lidocaine dosing

One series of studies in healthy volunteers measured
the duration of pain relief during IO infusion in theproximal humerus and proximal tibia. During the
90-minute observation period in the tibial study,
eight of the volunteers who had previously received
100 mg lidocaine required an additional 20 mg
lidocaine to keep the IO infusion pain level below five (on a scale of 0-10). No volunteers in thehumeral study, who had previously received 60 mg
lidocaine, required additional lidocaine dosing tokeep pain levels below five.3 A 2015 abstract notedthat the use of additional analgesics may be aneffective alternative to lidocaine alone and mitigate
the need for repeat lidocaine dosing.4 A volunteer
study conducted in 2016 compared doses of 40
mg followed by a flush, followed by placebo or an
additional 20 mg dose, in the sternum and proximal
humerus sites. This study indicated the second doseof 20 mg may not be needed for all patients in theproximal humerus for adequate pain mitigation.5

recommendations were developed based on research; foradditional information, please visit www.eziocomfort.com.

Site Maintenance/Monitoring
Extravasation or infiltration is the most common
complication associated with IO insertion and canlead to serious complications such as compartment
syndrome and soft tissue necrosis. The IO insertionsite should be monitored frequently for any signs of
extravasation/ infiltration, localized inflammation, or
dislodgement, particularly in the first half hour after
insertion, anytime the IO catheter is manipulated,and during infusion of vasopressors, vesicants, andwith high infusion rates, but at least hourly during all
infusions.6 Specific serial monitoring of the involved
limb and IO infusion for any symptoms of potential
complications includes, but is not limited to, fever,a decreased flow rate or alarm on infusion pumps,
change in patient response to medications, limb
discoloration, swelling (this may include serial
circumferential measurements for obese or patientswith chronic edema), pain (with active or passive
motion), paresthesias, skin feeling cool or warm,

42

43

CARE AND MAINTENANCE OF THE EZ-IO® CATHETER

pulses, firmness or taut feel to all areas of limb as

feeling cool or warm, pulses, firmness, or taut feel tocompared to other limb and/or previous assessments.

area as compared to other limb.

Ultrasound confirmation of placement may also be
helpful as an adjunct to physical examination.7,81Davlantes C, Puga T, Montez D, Philbeck T, Miller L, DeNoia E.
48 Hours dwell time for intraosseous access: A longer-term

Organizational policy should dictate care of theinfusion using a temporary solution. Crit Care Med 2016;44

insertion site.

(12):140.TS
2

intraosseous insertion provides safe and effective vascularPatient Activity

access for emergency patients. Ann Emerg Med 2008;52(4):Ambulation should be discouraged with lower
extremity EZ-IO® Catheters in place. For the proximal

S152.TS3

4extended dwell: A preliminary report. Ann Emerg Med 2015;

above shoulder level), as this may lead to needle

66(4);S5.TS
5Montez D, Puga T, Davlantes C, Philbeck T. IO infusion pain
mitigation in the sternum and proximal humerus: Establishing

EZ-IO Catheter removal unless instructed by the®

a regimen. Crit Care Med 2016;44(12):154.TS

treating clinician.
6

Atanda A Jr, Statter MB. Compartment syndrome of the leg
after intraosseous infusion: guidelines for prevention, early

RemovalTo withdraw the catheter, remove the EZ-Connect®

Overbaugh R, Davlantes C, Miller L, Montez D, Puga T, Philbeck
TE. Intraosseous vascular access catheter appears safe during

45 degrees) but never past 90-degrees (e.g. elevateddislodgement. There are no activity restrictions after

Philbeck TE, Miller LJ, Montez D, Puga T. Hurts so good;easing IO pain and pressure. JEMS 2010;35(9):58-69.TS

humerus IO site, movement in the affected arm
should be minimized (ideally abducted no more than

Fowler RL, Pierce A, Nazeer S, et al. 1,199 case series: Powered

detection, and treatment. Am J Orthop 2008;37:E198-200.
7Tsung HW, Blaivas M, Stone MB. Feasibility of point-of-care

Extension Set and EZ-Stabilizer® dressing. Attachcolour Doppler ultrasound confirmation of intraosseous needle

a Luer Lock syringe to the hub. While maintaining

placement during resuscitation. Resuscitation 2009;80:665-8.

axial alignment, twist the syringe and catheter
clockwise while pulling straight out. Do not rock or

8Saul T, Siadecki SD, Berkowitz R, Rose G, Matilsky D. The
accuracy of sonographic confirmation of intraosseous line
placement vs physical examination and syringe aspiration.

bend the catheter during removal. Dispose of all

Am J Emerg Med 2015; article in press. http://dx.doi.org/

sharps in a proper sharps container. Apply pressure

10.1016/j.ajem.2014.12.034.

over the site as needed. Dress the site.
Post-IO removal, monitor and/or instruct the patientand family or health care provider to monitor the
involved limb for any signs of delayed presentationof symptoms of potential complications including,but not limited to, fever, discoloration, swelling, pain(with active or passive motion), paresthesias, skinEZ-IO® DRIVER AND TRAINING DRIVER

EZ-IO® Driver andTraining Driver

Storage:•stored at temperatures between -20°C to 50°C

The EZ-IO® Driver is a sealed, hand-held, lithium
battery-powered medical device.

The EZ-IO® Driver and accessories may be(-4°F to 122°F)•

When storing in the yellow, soft-sided case
(Vascular Access Pak, VAP) remove the trigger

Useful Life of EZ-IO® Driver

guard to prevent accidental activation of the

The life expectancy and number of approximate

EZ-IO® Driverinsertions is dependent on multiple factors: actual•

Additional product information can be foundusage, bone density, insertion time, storage

in the driver Instructions for Use and atconditions, and frequency of driver testing. As with

www.ArrowEZIO.com

any emergency medical device, carrying a backup isstrongly advised.

••

In the unlikely event of driver failure, remove the

EZ-IO® Driver LED will be solid green when

EZ-IO® Driver, grasp the needle set by hand, andtrigger is activated and has sufficient power

advance the needle set into the medullary space

EZ-IO® Driver LED will blink red when thewhile twisting the needle set clockwise/counter-trigger is activated, and the driver is approachingclockwise as described below in the Manualthe end of its battery life, indicating that theInsertion Technique.

EZ-IO® Driver must be replaced

Manual Insertion Technique*
Do not use excessive force during insertion. Let the

1.	 Push needle set tip through the skin until tip

EZ-IO® Driver do the work, and allow the beveled

rests against the bone (if not already partiallyneedle set to cut through the bony cortex as it ispenetrated with the driver). At least one black

slowly advanced. Applying too much pressure on

depth mark must be visible above the skin forthe driver (especially during insertions in the tibia,

confirmation of adequate needle set length.

where the cortex is thicker) may cause the user to

2.	 Hold the needle set with the catheter hub andperceive that the driver is “bogging down” or losing

stylet as one piece (ensuring the stylet and hub

power during insertion.

remain screwed together).
3.	 Rotate clockwise/counter-clockwise while

Battery Information:••

applying gentle, moderate, steady downward

EZ-IO® Drivers are sealed and not intended topressure without rocking the needle set. Allow

be openedrotation and pressure to penetrate the bone

Batteries are not replaceable

cortex, not excessive force.

44

45

EZ-IO® DRIVER AND TRAINING DRIVER

4.	 Stop insertion when a change in resistancedetach, clean and soak lanyard and trigger

is felt as a “give” or “pop” indicating entry toguard). Use soft, bristled brush to remove any

medullary space in pediatric patients. In adultvisible soil or debris, paying particular attention

patients, advance needle set approximately 1-2

to crevices and seam.

cm after entry into medullary space (felt as a

3.	 Spray or wipe the exterior surface of thechange in resistance); in the proximal humerus

EZ-IO® Driver with the antimicrobial solution

for most adults, the needle set should becommonly used by your institution, making

advanced 2 cm or until hub is flush or against

sure to follow the antimicrobial manufacturer’s

the skin.

recommendations.

5.	 Stabilize needle set hub and remove stylet.

4.	 Gently wipe exterior surfaces with gauze pads
until visible debris is removed.

6.	 Proceed as usual.

5.	 Clean and manipulate trigger using cloth* Manual insertion of IO access is recommended only when thedriver is unavailable or inoperable. Use of the driver optimizes

moistened with selected antimicrobial solution.

tactile feedback and sensitivity. Clinicians can more easily discern

6.	 Using sterile swabs, moisten with selected

when the needle set passes from the hard outer bone cortex into

antimicrobial solution, gently clean inside

the less dense medullary space.1 The mechanized driver creates a

opening around metal drive shaft.

clean entry hole the size of the catheter.2 See Figures 28a and 28b.

1

Miller L, Philbeck T, Bolleter S, Garcia G. Tactile feedback
comparison of three types of intraosseous access devices forneedle insertion accuracy. Ann Emerg Med 2010;56(3):S133.TS

2

Teleflex internal study done in cadaveric bone.

7.	 After cleaning, inspect to ensure no visible
debris remains, and no damage has occurred
to the driver.
8.	 Dry driver with soft, clean cloth (re-attachlanyard and trigger guard), and return toappropriate location.

EZ-IO® Driver Cleaning
Specific information and direction on the EZ-IO®

Do not immerse or use excessive amount of liquid

Driver cleaning is outlined below. This information

when performing cleaning and disinfecting.

can also be found in the EZ-IO® Driver’s Instructions
for Use. The instructions can also be found at

EZ-IO® Driver Sterilization

www.ArrowEZIO.com.

If the clinical environment requires the sterilizationof the EZ-IO® Driver, the EZ-IO® Driver has been

Cleaning and Disinfection of the EZ-IO Driver:validated using the STERRAD® 100S. STERRAD® is a1.	 Maintain body substance isolation (BSI) or

product of Advanced Sterilization Products, division®

personal protective equipment (PPE) precautions.
2.	 Wipe entire exterior surface of EZ-IO® Driverwith soft, clean moistened cloth. (If supplied,of Ethicon Inc., a Johnson & Johnson Company.

EZ-CONNECT® EXTENSION SET

EZ-IO® Training Driver

tubing, secures the EZ-IO® Catheter in place withThe EZ-IO® Training Driver is intended for training

the EZ-Stabilizer® dressing, and helps preventand demonstration only. Training drivers typically

accidental dislodgement.

incur heavier usage, more frequent transport,
and frequent handling by inexperienced users.

The EZ-Connect® Extension Set contains approximately

Regulatory, quality, and cleaning differences preclude

1 mL of volume when primed. The EZ-Connect®

the training driver from being used for patient care.

Extension Set was bench tested in 2010 to determine
the power infusion pressure at which the EZ-Connect®

Trigger Guard/Vascular Access Pack (VAP)

tubing ruptures. This test was conducted three

The Arrow EZ-IO Vascular Access Pack is a soft

times, each with a new EZ-Connect® Extension Set

sided yellow case that includes a built-in cradle

and the EZ-Connect® Extension Set clamped. The

for the driver. Storing the driver in the cradle with

EZ-Connect® Extension Set ruptured at 200 psi,the trigger guard in place may cause inadvertent

195 psi, and 190 psi.1®

®

activation of the driver, resulting in depletion of thebatteries. To prevent this situation, the trigger guard

Infection Prevention/Control

should be completely removed when storing the

The EZ-Connect® Extension Set uses the Robertsite®

driver in the cradle.

Needleless Connector by Halkey Roberts. Studies
evaluating the integrity of the valve’s microbial

EZ-Connect® Extension Set

properties found the system maintains adequate

The EZ-Connect® Extension Set (extension tubing

Observe the following instructions for proper use ofwith a 90° angle, supplied with needle set) is a

the EZ-Connect® Extension Set:

needleless connector system with a split septum•

microbial barrier protection.2(non-mechanical) valve, swabable negative fluid
displacement port and Luer Lock adapter. The

Do NOT use any instruments to tighten
connections•

To prevent valve damage, do NOT use needles

needleless connector enables attachment of aor blunt cannula to access the swabable valve.

syringe to the extension set, rather than directly

Non-standard syringes or connectors can

attaching a syringe to the EZ-IO® Catheter (which

damage the swabable valve

should be avoided unless aspirating for laboratory•

Prior to accessing the valve, swab the surface ofsamples, administration of very small volume

the valve with alcohol and let it air dry (or follow

medication doses and other special circumstances).

your institution’s policy/protocol)

The EZ-Connect® Extension Set is low-profile,designed to prevent kinking of the extension

46

47

COMPLICATIONSAll components of the EZ-IO® System, including theTeleflex records indicate a much lower rate –EZ-Connect Extension Set are DEHP-free and are

fewer than one incident per 100,000 insertions.

not manufactured using natural rubber latex.

[See Osteomyelitis, page 57]®

EU: The EZ-Connect® Extension Set is compatible

Rare complications also include localized infections,with any syringe or connector made to the ISO/IEC

penetration through posterior cortex of the bone,

DIS 80369-7 specification.

catheter breaking, bending or clogging, dermalabrasion, and difficulty removing the IO device.

12

Vidacare Study #2010-16, internal bench test data, Teleflex

Complications can usually be prevented or limited

Incorporated.

by proper insertion technique and frequent monitoring

http://www.halkeyroberts.com/userfiles/files/Medical%20

of the infusion site.4 For further information visit:

Miscellaneous/RNV%20Book/RNV%20Book%202016.pdf
Accessed: 02/08/2017.

https://www.teleflex.com/en/usa/ezioeducation/index.html [See Intraosseous Complications, page 49]

Complications

Will Infusing Drugs Through the IO Space
Cause Long-Term Damage to Bone Marrow?

What Are the Complications Associatedwith IO Vascular Access?

No long-term damage to human bone has been

Historically, the overall rate of serious complications

routine intraosseous infusions; however, caution isassociated with IO insertion and infusion has beenadvised with the use of long-term or repeatedless than 1%. [See Intraosseous Complications,infusions of hypertonic agents in the same bone.

page 49]

A 1947 review of 495 pediatric patients with IO•

Extravasation or infiltration of fluid is the mostplacement found that two patients who received IO

commonly reported complication of IO catheters

hypertonic saline infusions developed osteomyelitis

Compartment syndrome can result if a large

and advised against infusing hypertonic fluids via

extravasation or infiltration goes undetected,

the IO route.5 A 1997 review of preclinical and clinicalwhich may require surgical intervention

studies reported that hypertonic saline could beor amputation

infused through the IO route in combat situations,

Osteomyelitis is a rare but serious infection.

but recommended limiting the infusion to a single

The most often-quoted rate is 0.6% from adose.6 Most published studies are preclinical andpublished 1985 meta-analysis by Rosetti of IO

suggest short term doses of hypertonic solutions

procedures done before the availability ofand vesicants to be safe in the preclinical setting.7

modern techniques and devices.3 In the absence

One preclinical study in swine reported Adriamycin,

of a more recent study, the literature andadministered in the same bone three times over a••

documented in known medical literature from

COMPLICATIONS

in the bones used for the infusions in 10 of 14

Is Fat Embolism or Thromboembolism an
Issue With IO Infusion?

animals. The authors did a follow-up study designed

Clinically significant fat embolism from IO

to explore different drug administration regimens

administration has not been reported in known

designed to prevent these complications. The IO

medical literature. [See Embolism, page 55]

72-day period, caused osteomyelitis and/or fracturesdelivery of lower dose and diluted concentrations ofin less tissue abnormality when compared withIs Air Embolism a Possibility through an IO
Catheter?

higher dose/higher concentration. Authors concluded

Yes. Air embolism can be introduced into thethat use of the IO route with rotation of sites may

circulatory system by any vascular route including

be a feasible option for Adriamycin or otherperipheral venous access, central venous access,vesicant delivery.8 A 2002 preclinical study in swine

arterial access, or intraosseous access. A primed

reported marrow damage after multiple infusions

syringe, extension set or infusion tubing shouldof hypertonic saline.9 Any drug with the potential toalways be placed on the IO catheter hub immediately

cause sclerosis or damage to veins has the potential

after EZ-IO® Catheter insertion.

Adriamycin was determined to be safer and resulted

to damage intraosseous vessels and tissue especiallyversus benefit ratio of administering these drugs

Does Teleflex Track Complications
Associated with the EZ-IO® Device?

via the IO route should be carefully evaluated priorYes. Teleflex tracks any reported problems or

to use. Potential mitigation practices would include

complications associated with the EZ-IO® Device

rotation of sites, flushing of the medullary spacein accordance with U.S. FDA and global out of the

post-infusion with normal saline, and use of diluted

United States (OUS) country-specific regulatory

concentrations when acceptable. [See Effects of IO

agency requirements for medical devices.

with repeated or long-term doses. As such, the risk

Access on Growth Plates and Bone Repair, page 53]

1

adult intraosseous catheter complication and review of theDoes IO Insertion or Infusion Affect theliterature. Crit Care Med 2016;doi:10.1097/CCM.
0000000000001714 [April 7th. Epub ahead of print].

Growth Plate in Pediatric Patients?
Though often listed as a theoretical complication

2

Petitpas F, Guenezan J, Vendeuvre T, Scepi M, Oriot D, Mimoz O.
Use of intraosseous access in adults: a systematic review. Critof IO access, no growth plate damage in pediatricpatients has been documented in known medical

Greenstein YY, Koenig SJ, Mayo PH, Narasimhan M. A serious

Care 2016;20:102. doi:10.1186/s13054-016-1277-6.
3

Rosetti VA, Thompson BM, Miller J, Mateer JR, Aprahamian C.

literature. [See Effects of IO Access on Growth

Intraosseous infusion: an alternative route of pediatricPlates and Bone Repair, page 53]

intravascular access. Ann Emerg Med 1985;14(9):885-8.
4

Atanda A Jr, Statter MB. Compartment syndrome of the leg
after intraosseous infusion: guidelines for prevention, early
detection, and treatment. Am J Orthop 2008;37:E198-200.

48

49

INTRAOSSEOUS COMPLICATIONS

5Heinild S, Sondergaard T, Tudvad F. Bone marrow infusion inchildhood: Experiences from a thousand infusions. J of Pediatr
1947;30(4):400-12.

6

Dubick MA, Kramer GC. Hypertonic saline dextran (HSD) andmost common severe complication of IO access.2,6
As with IV access, extravasation of certain medications
may cause damage to soft tissue. Therefore, careful

intraosseous vascular access for the treatment of haemorrhagic

monitoring of the insertion site is imperative. [Seehypotension in the far-forward combat arena. Ann Acad Med

Compartment Syndrome, page 51]

Singapore 1997;26(1):64-9.
7Bebarta VS, Vargas TE, Castaneda M, Boudreau S. Evaluationof extremity tissue and bone injury after intraosseous hypertonic

8

Although uncommon, other reported complications

saline infusion in proximal tibia and proximal humerus in adult

have included fracture, soft tissue and/or dermalswine. Prehosp Emerg Care 2014. doi:10.3109/109031.27.2014.

damage, failure to infuse due to catheter bending

912704.

or clogging, and emboli potentially related toLima R, Navarro L, Cesani F. Repeated doses of adriamycin

IO access.7-11,21,22

may be safely delivered through the intraosseous route indifferent bones in swine. Blood 2010:116(21):4344. Available

9

online at:

EZ-IO® Device Complications(accessed 05/26/2017).

As of May 2017, over 85 clinical trials or case studies

Alam HB, Punzalan CM, Koustova E, Bowyer MW, Rhee P.

involving the EZ-IO® Device have been reported inHypertonic saline: intraosseous infusion causes myonecrosis ina dehydrated swine model of uncontrolled hemorrhagic shock.
J Trauma 2002;52(1):18-25.

the clinical literature, including over 5,400 patients.12
The rate of EZ-IO® Device related serious
complications reported in literature and to Teleflex

Intraosseous Complications

through clinical communications and global
regulatory channels is < 0.001% (less than one per
100,000 EZ-IO® Catheter placements based on three

Historically, the documented overall complication

million needle sets sold). The most frequently reported

rate associated with IO insertion and infusion is lessserious complication is compartment syndrome

than 1%. In a 1985 meta-analysis of over 4,200

which has been reported with three resulting inpatients, the most common IO complication was

amputations.13-20 Two cases of osteomyelitis haveinfection, including osteomyelitis (0.6%), and was

been reported through clinical communication andattributed to IO placement in bacteremic patients or

filed with the FDA’s Medical Device Reporting (MDR)

prolonged infusions.

system, but none have been reported for the EZ-IO®

1,2

3

Device in the literature. Non-serious complications
With modern technological devices and procedures,

included uncomplicated extravasation, infiltration,

extravasation is the more prevalent complication

slow flow rate, dislodgement, inability to flush,

reported.

4,5

While simple extravasation itself may beleakage, problems with device, difficulty withunremarkable, compartment syndrome may occur if

removal of device, local inflammation, and a case of

extravasation continues undetected and may be thedermal abraision.21 Complications can usually be

INTRAOSSEOUS COMPLICATIONS

prevented or severity minimized by proper
insertion technique and frequent monitoring of
the infusion site.

9

Katz DS, Wojtowycz AR. Tibial fracture: a complication of
intraosseous infusion. Am J Emerg Med 1994;12(2):258-9.

10 Bowley DM, Loveland J, Pitcher GJ. Tibial fracture as acomplication of intraosseous infusion during pediatricresuscitation. J Trauma 2003;55(4):786-7.

In a 2005 prospective study of the EZ-IO® Device in

11 La Fleche FR, Slepin MJ, Vargas J, Milzman DP. latrogenic

250 adult patients, Davidoff et al. reported an overallbilateral tibial fractures after intraosseous infusions attempts incomplication rate of 3%, with failure to delivera 3-month-old infant. Ann Emerg Med 1989;18(10):1099-1101.

medications the most predominant.23 These
complications were generally associated with failure
to syringe-flush the catheter following insertion –12 Teleflex Arrow® EZ-IO® internal database and Arrow® EZ-IO®
bibliography as of March 01, 2017.
13 Dolister M, Miller S, Borron S, et al. Intraosseous vascularaccess is safe, effective and costs less than central venous

a critical step for IO infusions. There were no cases

catheters for patients in the hospital setting. J Vasc Accessof osteomyelitis, embolism, fracture, infection,

2013;14(3):216-24. doi:10.5301/jva.5000130

extravasation, or compartment syndrome.

14 Khan LAK, Anakwe RE, Murray A, Godwin Y. A severe
complication following intraosseous infusion used during

1

Greenstein YY, Koenig SJ, Mayo PH, Narasimhan M. A Serious
adult intraosseous catheter complication and review of theliterature. Crit Care Med 2016;doi:10.1097/CCM.
0000000000001714 [April 7th. Epub ahead of print].

2

3

Petitpas F, Guenezan J, Vendeuvre T, Scepi M, Oriot D, Mimoz O.

report. Acta Anaesthesiologica Scandinavica 2015;doi:10.1111/

Rosetti VA, Thompson BM, Miller J, et al. Intraosseous

Gluckman W. Intraosseous cannulation. Emedicine Updated
article/908610-overview#a3. Accessed 02/08/2017.
Fowler RL, Pierce A, Nazeer S et al. 1,199 case series: Powered
intraosseous insertion provides safe and effective vascularaccess for emergency patients. Ann Emerg Med 2008;52(4):S152.TS

6 Paxton JH. Intraosseous vascular access: a review. Trauma
2012;14(3):195-232. doi:10.1177/1460408611430175.
Vidal R, Kissoon N, Gayle M. Compartment syndrome following
intraosseous infusion. Pediatrics 1993;91(6):1201-2.
8

16 Suominen PK, Nurmi E, Lauerma K. Intraosseous access inCrit Care 2016;20:102; doi:10.1186/s13054-016-1277-6.

May 2014. Available at: http://emedicine.medscape.com/

7

infants. BMJ 2011;342:d2778. doi:10.1136/bmj.d2778.

neonates and infants: risk of severe complications – a case

Ann Emerg Med 1985;14(9):885-8.

5

15 Taylor CC, Clarke NMP. Amputation and intraosseous access in

Use of intraosseous access in adults: a systematic review.

infusion: an alternative route of pediatric intravascular access.

4

resuscitation of a child. Inj Extra 2011; doi:10.1016/j.injury.
2011.05.015.

aas.12602.
17 Fetissof H, Nadaud J, Landy C, Millot I, Paris R, Plancade D.
Amines on intraosseous vascular access: A case of skin necrosis.
Ann Fr Anesth Reanim 2013;32(5):e89-90. http://dx.doi.org/
10.1016/j.annfar.2013.02.022.
18 Landy C, Plancade D, Gagnon N, Schaeffer E, Nadaud J,
Favier JC. Complication of intraosseous administration ofsystemic fibrinolysis for a massive pulmonary embolism withcardiac arrest. Resuscitation 2012;83:49-50. doi:10.1016/
j.resuscitation.2012.01.044.
19 Lee, PM, Lee C, Rattner P, Wu X, Gershengorn H, Acquah S.
Intraosseous versus central venous catheter utilization andperformance during inpatient medical emergencies. Crit Care
Med 2015;doi:10.1097/CCM.0000000000000942.
20 Oesterlie GE, Petersen KK, Knudsen L, Henriksen TB. Crural

Smith R, Davis N, Bouamra O, Lecky F. The utilisation of

amputation of a newborn as a consequence of intraosseous

intraosseous infusion in the resuscitation of paediatric major

needle insertion and calcium infusion. Pediatr Emer Care

trauma patients. Injury 2005;36(9):1034-8.

2014;30:413-414.

50

51

COMPARTMENT SYNDROME

21 Overbey JK, Kon AA. Dermal abrasion experienced as anadverse effect of the EZ-IO®. J Emerg Med 2015;http://dx.doi.org/
10.1016/j.jemermed.2015.09.003.
22 Azan B, Teran F, Nelson BP, Andrus P. Point-of-care ultrasoundinadequate needle length leading to incomplete
penetration of the cortex, over-penetration throughthe opposite cortex, extravasation through thediagnosis of intravascular air after lower extremity intraosseous

foramina of a nutrient vessel, multiple punctures

access. J Emerg Med 2016;51(6):680-683. http://dx.doi.org/(for example, due to multiple IO access attempts)

10.1016/j.jemermed.2016.05.064.

in the same bone, fracture, and needle dislodgement.

23 Davidoff J, Fowler R, Gordon D, et al. Clinical evaluation of anovel intraosseous device for adults. J Emerg Med 2005;30(10Suppl):S20-3.TS

In his discussion of compartment syndrome, Paxton
notes that the potential risk may also be influenced
by factors which include the type of fluid (e.g., fluid

Compartment Syndrome

osmolarity, isotonic vs. hypertonic), length ofinfusion, total volume, and rate of fluid infused.2,3
In extreme cases, amputation of a limb is necessary

Compartment Syndrome Overview

if the compartment syndrome is not recognized“Compartments” are composed of muscle tissue,

soon enough or is not adequately treated. Oncenerves, and blood vessels separated and surroundedrecognized, treatment of compartment syndromeby thick layers of non-expandable tissue (fascia).

consists primarily of removing the increased

Compartment syndrome occurs when swellingpressure source and careful monitoring, assuming

within that confined space causes the compression

circulation has not been compromised. In moreof those nerves, blood vessels, and muscle due tosevere cases, fasciotomy (surgically opening thethe lack of ability to expand outward. This may befascia surrounding the compartment to releasecaused by instillation of fluid into the soft tissue

the pressure) may be required to restore circulation.

outside the vascular space. The most common site
swelling within the compartment can progress to

IO Access-Associated Compartment
Syndrome in the Literaturecompression of blood vessels within the compartment

Eight pediatric cases of compartment syndrome

causing a lack of oxygenation and eventually,

were reported in the medical literature between 2008

necrotic tissue. When the condition is attributedand 2016.2,4-9 Contributing factors included improper

to IO access, compartment syndrome is usuallytechnique, catheter dislodgement, and prolonged

secondary to infiltration and/or extravasation – theinfusion with caustic agents. Published adultmost prevalent complication of all forms of IO

cases include a 2011 case in which IO access was

vascular access, including the EZ-IO Device.

achieved on the second attempt in the same limb

Compartment syndrome usually occurs when(clinicians did not believe the first attempt

clinicians do not recognize early signs of infiltration

penetrated the cortex) and ten hours post-infusion,

and/or extravasation, and may be secondary tosymptoms of ischemia were present. The authors

for compartment syndrome is the lower leg. The®

1

COMPARTMENT SYNDROME

removed the IO catheter and a compartment release1

syndrome related to IO infusion was reported in2013 in which IO access was established in the

Crit Care 2016;20:102. doi:10.1186/s13054-016-1277-6.
2

for fluid infusion. IO catheter placement is

detection, and treatment. Am J Orthop 2008;37:E198-200.
34catheters for patients in the hospital setting. J Vasc Access

The first known case of humeral compartment

2012;doi:10.5301/jva.5000130.TS
5Khan LAK, Anakwe RE, Murray A, Godwin Y. A severe
complication following intraosseous infusion used during

affected limb was reported in a 2017 case study.

resuscitation of a child. Inj Extra 2011; doi:10.1016/j.injury.

In this case a patient with a severe coagulopathy
developed compartment syndrome eight days post-

Dolister M, Miller S, Borron S, et al. Intraosseous vascularaccess is safe, effective and costs less than central venous

manual IO devices; two resulting in limb amputations.
syndrome presumed to be due to IO access in the

Paxton JH. Intraosseous vascular access: a review. Trauma
2012;14(3):195-232. doi:10.1177/1460408611430175.

contraindicated for fractured bones. Other casesof compartment syndrome have occurred using

Atanda A Jr, Statter MB. Compartment syndrome of the leg
after intraosseous infusion: guidelines for prevention, early

fractured tibia of an adult multi-trauma patient
11

Petitpas F, Guenezan J, Vendeuvre T, Scepi M, Oriot D, Mimoz O.
Use of intraosseous access in adults: a systematic review.

was done. A second case of adult compartment
10

2011.05.015.
6

Carreras-Gonzáles E, Brio-Sanagustin S, Guimera I, Crespo C.

IO catheter removal requiring treatment with

[Spanish]. Complication of the intraosseous route in a newborn

a fasciotomy.

infant. [Complicación de la via intraósea en un neonate]. Med

12-21

Intensiva 2011. doi:10.1016/j.medin.2011.05.004.

These cases underscore the importance of adequate
training, appropriate selection of IO needle set andinsertion site, proper technique, confirming proper
placement of the IO catheter within the medullary7

Taylor CC, Clarke NMP. Amputation and intraosseous access ininfants. BMJ 2011;342d2778;doi:10.1136/bmj.d2778.

8

Moen TC, Sarwark JF. Compartment syndrome following
intraosseous infusion. Orthopedics 2008;37(12):E198-200.

9

Suominen PK, Nurmi E, Lauerma K. Intraosseous access inspace, frequent reassessments, and stabilization

neonates and infants: risk of severe complications – a caseof all IO devices. Early detection of extravasation

report. Acta Anaesthesiologica Scandinavica 2015;doi:10.1111/

and prevention of compartment syndrome canusually be accomplished through frequent monitoringaas.12602.
10 Cotte J, Prunet B, d’Aranda E, Asencio Y, Kaiser E. [Acompartment syndrome secondary to intraosseous infusion].

of the insertion site and the involved extremity,

Ann Fr Anesth Reanim 2011;30(1):90-1. doi:10.1016/j.annfar.

particularly during prolonged infusion, prolonged

2010.05.038 [Article in French].

transport times, in patients with multiple comorbidities such as coagulopathic conditions,and during administration of large fluid volumes,
vasopressors, and vesicants.2,22

11 d’Heurle A, Archdeacon MT. Compartment syndrome after
intraosseous infusion associated with a fracture of the tibia.
JBJS Case Connect 2013;3(e20):1-3.
12 Thadikonda KM, Egro FM, Ma I, Spiess AM. Deltoid
compartment syndrome: A rare complication after humeral
intraosseous access. Plast Reconstr Surg Glob Open 2017;
5:e1208. doi:10.1097/ GOX.0000000000001208; Published
online 24 January 2017.

52

53

EFFECTS OF IO ACCESS ON GROWTH PLATES AND BONE REPAIR

13 Wright R, Reynolds SI, Nachtsheim B. Compartment syndrome
secondary to prolonged intraosseous infusion. Pediatr Emerg
Care 1994;10(3):157.
14 Moscati R, Moore GP. Compartment syndrome with resultant

vascular access and reported earlier findings of a lackof evidence for lasting negative effects of IO infusionon the bone, growth plates, and marrow elements.1

amputation following intraosseous infusion. Am J Emerg Med

Lack of negative effect on the epiphyseal plate

1990;8(5):470-1.

subsequent to IO infusion has been demonstrated

15 Galpin RD, Kronick JB, Willis RB, Frewen TC. Bilateral lower
extremity compartment syndromes secondary to intraosseous
fluid resuscitation. J Pediatr Orthop 1991;11(6):773-6.
16 Gayle M, Kissoon N. A case of compartment syndrome

in several radiographic studies in the pediatricpopulation. Preclinical studies in swine and rabbit
models have supported similar conclusions.2-4

following intraosseous infusions. Pediatr Emerg Care 1994;
10(6):378.
17 Launay F, Paut O, Katchburian M, Bourelle S, Jouve JL, Bollini G.
Leg amputation after intraosseous infusion in a 7-month-old
infant: a case report. J Trauma 2003;55(4):788-90.
18 Vidal R, Kissoon N, Gayle M. Compartment syndrome following
intraosseous infusion. Pediatrics 1993;91(6):1201-2.
19 Burke T, Kehl DK. Intraosseous infusion in infants. Case report ofa complication. J Bone Joint Surg Am 1993;75(3):428-9.
20 Ribeiro JA, Price CT, Knapp DR Jr. Compartment syndrome of
the lower extremity after intraosseous infusion of fluid. A reportof two cases. J Bone Joint Surg Am 1993;75(3):430-3.
21 Simmons CM, Johnson NE, Perkin RM, van Stralen D.
Intraosseous extravasation complication reports. Ann Emerg
Med 1994;23(2):363-6.

Clinical Research
A 1947 clinical study examined long-term boneabnormalities during radiographic follow-up in 72
pediatric patients who received IO insertion. No
patient exhibited radiographic bone abnormality
and bone growth was normal for all patients in the
study. Thirty-six of those patients were followed
up to a year; 18 were followed up to two years and
18 were followed over two years post-infusion.5 A
1997 study performed radiographic measurementsof the tibias in pediatric patients 12 months after
IO infusion. Results demonstrated no significant

22 Waltzman ML. Amputation and intraosseous access in infants-

difference in tibial lengths.6 In 2003, a clinical study

Intraosseous access: It’s the operator and not the device. BMJ

of pediatric patients receiving IO infusions revealed

2011;342:d2778. http://www.bmj.com/rapid-response/2011/11/03/intraossesous-access-its-operator-and-not-device.

Effects of IO Accesson Growth Plates
and Bone Repair

no radiographic differences in tibia width or length.
The follow-up radiographs were performed on
average 29 months after infusion.7 A 2003 overview
article is also supportive of these findings.8

Preclinical Research
One preclinical study of IO infusion in young swine
found no growth disturbances or growth plate

Effect on Epiphyseal (Growth) Plates

abnormalities after two and six months.2 AnotherA 1990 review article published in the New Englandpreclinical study found IO infusion of saline andJournal of Medicine stressed the relative safety of IO

bicarbonate did not damage growth plates. The

EFFECTS OF IO ACCESS ON GROWTH PLATES AND BONE REPAIR

researchers observed loss of bone trabeculae

coagulation and fibrin formation.13 Complete healing,supporting the growth plate, but the loss wasto the point where x-ray can no longer detect the

rapidly repaired. A 1993 preclinical study foundhole, varies from weeks to months.14

3

no changes in bone growth or epiphyseal injury
related to IO infusion.4 Boysen’s 2016 swine study
compared administration of tranexamic acid (TXA)

1

Fiser DH. Intraosseous infusion. N Engl J Med 1990;322(22):1579-81.

2

Brickman KR, Rega P, Koltz M, Guinness M. Analysis of growthby the IO and IV route. To assess for potential boneplate abnormalities following intraosseous infusion through themarrow lesions caused by drug toxicity, aproximal tibia epiphysis in pigs. Ann Emerg Med 1988;17(2):pathologist did blinded postmortem histological121-3.
3

Dedrick DK, Mase C, Ranger W, Burney RE. The effects of

microscopic assessments of sections of the proximal

intraosseous infusion on the growth plate in a nestling rabbit

tibial articular cartilage, epiphysis, growth plate,model. Ann Emerg Med 1992;21(5):494-7.

and metaphysis in limbs that had the IO TXA

4

infusions: effects on the immature physis – an experimental

infusion with the non-affected limb. All marrow
was normal with no differences between limbs.9

Bielski RJ, Bassett GS, Fideler B, Tolo VT. Intraosseousmodel in rabbits. J Pediatr Orthop 1993;13:511-5.

5

Heinild S, Sondergaard T, Tuvad F. Bone marrow infusion inchildhood. J Pediatr 1947;30(6):400-412.

Bone Repair after IO Infusion

6

intraosseous infusion: a prospective, radiographic analysis.

The Rosetti meta-analysis (1985) reported multiple

Pediatr Emerg Care 1997;13(3):186-8.

follow-up studies on marrow and bone from 24hours post infusion through 22 months.10 Periostitis

7

radiographic analysis. Pediatr Emerg Care 2003;19(6):397-401.
8

less or normal; and no long-term bone changes
were noted post isotonic infusion.

Claudet I, Baunin C, Laporte-Turpin E. Long-term effects
on tibial growth after intraosseous infusion: a prospective,at the injection site cleared within 2-3 weeks;marrow cellularity after isotonic infusion was slightly

Fiser RT, Walker WM, Seibert JJ, et al. Tibial length following

LaRocco BG, Wang HE. Intraosseous infusion. Prehosp Emerg
Care 2003;7:280-5.

9Boysen SR, Pang JM, Mikler JR, Knight CG, Semple HA,
Caulkett NA. Comparison of tranexamic acid plasma

Based on a 2010 preclinical study, sealing of thebone (to the point at which IO placement andinfusion can be accomplished in the same bone)takes approximately 48 hours post-IO catheter
removal.11 Early IO research articles suggested aninterval of 48 hours before attempting an IO infusion

concentrations when administered via intraosseous andintravenous routes. Am J Emerg Med 2016;http://dx.doi.org/
10.1016/j.ajem.2016.10.054.
10 Rosetti VA, Thompson BM, Miller J, et al. Intraosseous
infusion: an alternative route of pediatric intravascular access.
Ann Emerg Med 1985;14(9):885-8.
11 Miller LJ, Philbeck TE, Puga TA, Montez DF, Escobar GP.
A preclinical study to determine the time to bone sealing andin a limb previously accessed.12 By that time, fibrin

healing following intraosseous vascular access. Ann Emerg Med

formation and clotting may be sufficient to prevent

2011;58(4S):S240.TS

extravasation through the previous IO hole EO
since bone marrow fluid rapidly undergoes

12 Gunz FW, Dean RFA. Tibial bone marrow transfusions ininfants. Br Med J 1945;1(4389):220–1.

EO = Expert Opinion

54

55

EMBOLISM

13 d’Onofrio G, Zini G. Analysis of bone marrow aspiration fluidusing automated blood cell counters. Clin Lab Med 2015;35(1):25-42. http://dx.doi.org/10.1016/j.cll.2014.10.001.
14 Ginsberg-Peltz J. Time to bone healing after intraosseous

embolism was noted on autopsy in a seven monthold child.3 While the cause of death remained
undetermined, it was noted that the patient had

placement in children is ill defined. Pediatr Emerg Care 2016;no other vascular access other than the IO route.

32(11):799–800. doi:10.1097/PEC.0000000000000652.

However, the authors noted that air could have been
introduced during any of the attempts at central

Embolismvenous or arterial access, as well as by theThromboembolism

In the second case, multiple gas emboli were

Thromboembolism is not typically a complication

discovered in a post-mortem computed tomography

associated with IO infusions due to anatomy and(CT) scan in a four month-old child who died ofphysiology of circulation within the medullarysudden infant death syndrome.4 A bone marrowcavity. One known case is reported in the literatureaspiration needle had been used to provide IO

for an arterial thrombosis in a patient receiving an

vascular access. No alternative attempts at vascular

IO infusion. The authors were not certain of theaccess were noted. The author concluded that gas

cause of the thrombosis and exact mechanisms of

could have been introduced subsequent to thethe disease process were unclear. Two additional

method of infusing IO medications, and concluded

known cases have been reported through the FDA

that resuscitation with an inserted, disconnected

MedWatch system on infants that had multiple

intraosseous needle/catheter should be avoided.

IO route.

1cardiac co-morbidities and after prolonged cardiac
arrest before return of spontaneous circulation.2

A 2016 case reported on a patient in which theyfound a vascular air embolism via ultrasound when

Air Embolism

they were assessing the patient’s femoral vessels

As with any vascular access route, an air embolism

prior to arterial line placement on the same side as

can be introduced into the circulatory system bya limb that had an IO access placed. The authors

IO access. The determining factors favoring air

noted that it was possible air was introduced whenembolism are relative pressure gradients between

the patient injected IV heroin to that same leg; but

the vascular access site and atmospheric pressure,believe it was more likely the IO line or tubing wasand the size of the catheter.

not flushed or left open for a period of time.5

There are two known reports in published literature

One report of an air embolism potentially relatedof air embolism in pediatric patients after an IO

to IO infusion is within the FDA MDR database.

infusion. In the first case, a cerebral arterial air

The embolus was diagnosed by CT scan. The air

EMBOLISM

embolus was removed by syringe aspiration from

A 1997 swine study examined IO infusion during

the vessel without subsequent complications.

CPR and found no increase in fat embolism in the IO

A primed syringe, extension set or infusion tubing

group compared to control groups, which received

should always be placed on the IO catheter hub

no IO infusions.7 Another swine study found low

immediately after insertion, and should remain inlevels of fat embolism (one to three emboli perplace until catheter removal to help prevent thehigh powered field in 30% of the specimens). The

possibility of air embolism.

researchers concluded that the risk of fat emboli
exists with IO access, but its clinical relevance is

Fat Embolism

unclear.11 In 2012, Lairet et al. reported finding

No known case of clinically significant fat embolism

fat emboli in the lungs of 32 of 39 swine that had

resulting from IO administration has been reported inreceived blood transfusions using high pressure

the medical literature, although preclinical trials haveaveraging 604 mmHg.12 The infusion pressures

shown microscopic fat emboli in the lungs after highwere double the maximum pressure typically usedpressure IO infusion.

for IO infusion and, in contrast to Orlowski’s earlier

6-8

work, Lairet’s study did not include control animals
The risk of fat embolism associated with IO infusion

in which there was no IO infusion or infusion withhas been studied in preclinical trials and reported insaline, or infusion with typical pressure (300 mmHg).

the clinical literature. In a canine study, Orlowski et

Rubal’s 2015 swine study investigated the occurrence

al. examined the prevalence of fat and bone marrowof fat intravasation resulting from IO flush andemboli in the lung following IO infusion of hypertonic

infusion. Intravasated fat was assessed using aand emergency drugs. Researchers found nolipophilic fluoroprobe and vascular ultrasounddifference in the mean number of fat and bone

imaging. Fat intravasation was observed during all

marrow emboli per square millimeter of lung tissue

IO infusion regimens, with subclinical pulmonary

compared to the control group, who received normal

fat emboli persisting 24 hours post infusion. It wassaline by the IO route. In 1995, Plewa reported anoted that initial flush was a significant factor in

preclinical study examining hematologic parameters

fat intravasation, low levels of intravasation occurredwith IO and IV autologous blood transfusions.

with infusions ≤300 mmHg, fat intravasation and

The authors found all hematologic parametersbone marrow shear-strain increased with IO

remained within normal limits in both IO and IV

infusion rates, and intravasation was influenced bygroups, and concluded that IO blood transfusions

insertion site.

910

were hematologically safe, without risk of appreciable
hemolysis, disseminated intravascular coagulation,

In a case series of 18 pediatric patients receiving IO

or fat embolism syndrome.

infusion during resuscitation, one complication of

56

57

OSTEOMYELITIS

minor fat embolism was reported and described by
Moller as having “no clinical significance.”

13

12 Lairet JR, Bebarta V, Mathis D, et al. Comparison of intraosseous
infusion rates of blood under high pressure in an adulthypovolemic swine model in three different limb sites. Ann
Emerg Med 2012;60(4S):S75.

1

Launay F, Paut O, Katchburian M, et al. Leg amputation after
intraosseous infusion in a 7-month-old infant: a case report.
J Trauma 2003;55(4):788-90.

2

13 Moller JC, Tegtmeyer FK, Schaible TF, Sussmane JB. Intraosseous
puncture as vascular access in pediatric emergency andintensive care medicine. Anaesthesiol Reanim 1996;21(4):103-7.

FDA manufacturer and user facility device experience (MAUDE)
database. Available at: http://www.accessdata.fda.gov/scripts/
cdrh/cfdocs/cfMAUDE/search.cfm (accessed 01/20/16).

3

van Rijn RR, Knoester H, Maes A, van der Wal AC, Kubat B.

Osteomyelitis

Cerebral arterial air embolism in a child after intraosseous4

infusion. Emerg Radiol 2008;15(4):259-62.

Numerous research studies and reports in clinical

Hillewig E, Aghayev E, Jackowski C, et al. Gas embolism

literature have addressed the low incidence offollowing intraosseous medication application proven by
post-mortem multislice computed tomography and autopsy.

osteomyelitis risk in the IO space.

Resuscitation 2007:72:149-53.
5

Azan B, Teran F, Nelson BP, Andrus P. Point-of-care ultrasoundIn a 1985 meta-analysis of IO complications in overdiagnosis of intravascular air after lower extremity intraosseous

4,200 patients, the most common IO complication

access. J Emerg Med 2016;51(6):680-683. http://dx.doi.org/

was osteomyelitis at 0.6% and was attributed to10.1016/j.jemermed.2016.05.064.
6

Byrick R. Pulmonary fat embolism and intraosseous infusion.
Pediatr Crit Care Med 2001;2(2):184-5.

7

Fiallos M, Kissoon N, Abdelmodium T, et al. Fat embolism withthe use of intraosseous infusion during cardiopulmonary

IO access placement in bacteremic patients or
prolonged infusions.1 Six osteomyelitis cases havebeen reported in known literature since the 1985
meta-analysis by Rosetti et al.2-7

resuscitation. Am J Med Sci 1997;314(2):73-9.
8Rubal BJ, Meyers BL, Kramer SA, Hanson MA, Andrews JM,
DeLorenzo RA. Fat intravasation from intraosseous flush andinfusion procedures. Prehosp Emerg Care 2015;19(3):376-90.

9As of May 2017, over 85 clinical trials or case studies
involving the EZ-IO® Device have been reported in

doi:10.3109/10903127.2014.980475.

the clinical literature, involving over 5,400 patients.

Orlowski JP, Julius CJ, Petras RE, Porembka DT, Gallagher JM.

In aggregate, study results have reported no cases

The safety of intraosseous infusions: risks of fat and boneof osteomyelitis. While not reported in a publishedmarrow emboli to the lungs. Ann Emerg Med 1989;18(10):1062-7.
10 Plewa MC, King RW, Fenn-Buderer N, Gretzinger K, Renuart D,
Cruz R. Hematologic safety of intraosseous blood transfusion in

study, two cases of osteomyelitis subsequent to
EZ-IO® Device use have been reported to thea swine model of pediatric hemorrhagic hypovolemia. Acad

manufacturer through clinical communications.

Emerg Med 1995;2(9):799-809.

One case involved a pediatric patient with multiple

11 Hasan MY, Kissoon N, Khan TM, Saldajeno V, Goldstein J,
Murphy SP. Intraosseous infusion and pulmonary fat embolism.
Pediatr Crit Care Med 2001;2(2):133-8.

co-morbidities, including sepsis. Upon initial follow
up the patient was steadily improving, but complete

MEDICATIONS/FLUIDS

follow up data was unavailable. The second case wasconsistent with standard IV infusion practice.

an elderly patient treated with IV antibiotics.

Caution should be exercised with repeat doses of8

hypertonic fluids. Routine infusions of chemotherapy
1

Rosetti VA, Thompson BM, Miller J, et al. Intraosseous
infusion: an alternative route of pediatric intravascular access.
Ann Emerg Med 1985;14(9):885-8.

2

3

Platt SL, Notterman DA, Winchester P. Fungal osteomyelitis

advised, and follow each infusion with a normal
saline infusion to flush the chemotherapeutic agent

1993;9:149-50.

out of the marrow space.

Rosovsky M, FitzPatrick M, Goldfarb CR, Finestone H. Bilateral

24:72-3.

What Dosages Are Required for IO Infusion
Compared with IV Dosages?

Barron BJ, Tran HD, Lamki LM. Scintigraphic findings ofIntraosseous dosages are typically identical to IV

osteomyelitis after intraosseous infusion in a child. Clin Nucl

dosages. Clinical and preclinical studies demonstrate

Med 1994;19:307-8.

most drugs and fluids reach the central circulation

Stoll E, Golej J, Burda G, Hermon M, Boigner H, Trittenwein G.

with similar concentrations and clinical effects

review of the English-language literature. Pediatr Radiol 1994;

5

must be given via IO access extreme caution isand sepsis from intraosseous infusion. Pediatr Emerg Careosteomyelitis due to intraosseous infusion: case report and4agents is not recommended; but if chemotherapy

Osteomyelitis at the injection site of adrenalin through an
intraosseous needle in a 3-month-old infant. Resuscitation

through the IO route and the IV route.3-23

2002;53:315-8.
6

Dogan A, Irmak H, Harman M, Ceylan A, Akpinar F, Tosun N.
Tibial osteomyelitis following intraosseous infusion: a casereport. Acta Orthop Traumatol Turc 2004;38:357-60.

7Henson NL, Payan JM, Terk MR. Tibial subacute osteomyelitis
with intraosseous abscess: an unusual complication of
intraosseous infusion. Skeletal Radiol 2010; 40(2):239-42.

What Medications Have Been Administered
Successfully to Date (Via the IO Route)?
A list of medications that have been included in theclinical literature as administered via the IO routefollows on page 60.

doi:10.1007/s00256-010-1027-1029.
8

Teleflex Internal Database (as of March 01, 2017).

1

Voigt J, Waltzman M, Lottenberg L. Intraosseous vascularaccess for in-hospital emergency use: a systematic clinicalreview of the literature and analysis. Pediatr Emerg Care

Medications/Fluids

2012;28(2):185-998.TS
2

Neumar RW, Otto CW, Link MS, et al. Adult advanced cardio
vascular life support. 2010 American heart association
guidelines for cardiopulmonary resuscitation and emergency

What Fluids and Medications Can Be
Infused Via the IO Route?
Many fluids or medications that can be safely

cardiovascular care. Circulation 2010;122 (suppl 3):S729-67.
doi:10.1161/CIRCULATIONAHA.110.
3

Resuscitation Council guidelines for resuscitation 2015. Section

infused via peripheral IV route may be infused

1. Executive summary. Resuscitation 2015;95:1-80.

through the IO route using the same dose, rate,and concentration.1-4 Incompatible drugs and fluids
should be infused sequentially in a manner

Monsieurs KG, Nolan JP, Bossaert LL et al. European

4

Von Hoff DD, Kuhn JG, Burris HA, Miller LJ. Does intraosseousequal intravenous? A pharmacokinetic study. Am J Emerg Med
2008;26:31-8.

58

59

MEDICATIONS/FLUIDS

5

6

Hoskins SL, Kramer GC, Stephens CT, Zachariah BS. Efficacy of

sequence induction of anesthesia via the intraosseous route: aduring CPR. Circulation 2006;114:II_1204.TS

prospective observational study. Emerg Med J 2014;doi:10.1136/

Hoskins S, Nascimento P, Espana J, Kramer G. Pharmacokinetics
of intraosseous drug delivery during CPR. Shock 2005;23:35.

TS

7

Hoskins SL, Nascimento P Jr., Lima RM, Espana-Tenorio, JM,
Kramer GC. Pharmacokinetics of intraosseous and central
venous drug delivery during cardiopulmonary resuscitation.
Resuscitation 2012;83(1):107-12.

TS

8

Zuercher M, Kern KB, Indik JH, et al. Epinephrine improves
24-hour survival in a swine model of prolonged ventricularfibrillation demonstrating that early intraosseous is superior to

9

15 Barnard EBG, Moy RJ, Kehoe AD, Bebarta TS, Smith JE. Rapid

epinephrine delivery via the intraosseous humeral head route

emermed-2014-203740.
16 Schlimp CJ, Solomon C, Keibl C, et al. Recovery of fibrinogenconcentrate after intraosseous application is equivalent to theintravenous route in a porcine model of hemodilution. J Trauma
Acute Care Surg 2014;76(5):1235-42.
17 Spencer TR. Intraosseous administration of thrombolytics for
pulmonary embolism. J Emerg Med 2013;45(6)e197-200.
http://dx.doi.org/10.1016/j.jemermed.2013.05.057.
18 Johnson D, Dial J, Ard J, et al. Effects of intraosseous anddelayed intravenous administration. Anesth Analg 2011;112(4):intravenous administration of Hextend on time of administration

884-90. doi:10.1213/Ane.0b013e31820dc9ec.

and hemodynamics in a swine model. J Spec Oper Med 2014;

Burgert J, Gegel B, Loughren M. Comparison of tibial

14(1):79-85.

intraosseous, sternal intraosseous, and intravenous routes of

19 Anson JA, Sinz EH, Swick JT. The versatility of intraosseousadministration on pharmacokinetics of epinephrine during

vascular access in perioperative medicine: a case series.

cardiac arrest: a pilot study. AANA Journal 2012;80(4):S6-S10.

J Clin Anesth 2015;27(1)63-7. http://dx.doi.org/10.1016/

10 Johnson D, Garcia-Blanco J, Burgert J, et al. Effects of humeral

j.jclinane.2014.10.002.

intraosseous versus intravenous epinephrine on pharmacokinetics

20 Anson JA. Vascular access in resuscitation: Is there a role forand return of spontaneous circulation in a porcine cardiac arrest

the intraosseous route? Anesthesiology 2014;120(4):1015-31.

model: a randomized control trial. Ann Med Surg 2015;4(3):306-10. doi:10.1016/j.amsu.2015.08.005.

21 Hill SL, Thomas SHL, Flecknell PA, et al. Rapid and equivalentsystemic bioavailability of the antidotes HI-6 and dicobalt

11 Burgert JM, Johnson AD, Garcia-Blanco J, et al. The effects ofedetate via the intraosseous and intravenous routes. J Emergproximal and distal routes of intraosseous epinephrine

Med 2015;32(8):626-31. doi:10.1136/emermed-2014-204171.

administration on short-term resuscitative outcome measuresin an adult swine model of ventricular fibrillation: a randomized
controlled study. Am J Emerg Med 2016;34:49-53. doi:10.1016/
j.ajem.2015.09.007.
12 Hamed RK, Hartmans S, Gausche-Hill M. Anesthesia throughan intraosseous line using an 18-gauge intravenous needle for
emergency pediatric surgery. J Clin Anesth 2013;25(6):447-451.
doi:10.1016/j.jclinane.2013.03.013.
13 Aliman AC, Piccioni Mde A, Piccioni JL, Oliva JL, Auler Junior
JO. Intraosseous anesthesia in hemodynamic studies in children
with cardiopathy. Rev Bras Anestesiol 2011;61(1):41-9.
14 Loughren M, Banks S, Naluan C, Portenlanger P, Wendorf A,
Johnson D. Onset and duration of intravenous and intraosseousrocuronium in swine. West J Emerg Med 2014;XV(2):241-5.

22 Wong MR, Reggio MJ, Morocho FR, et al. Effects of intraosseous
epinephrine in a cardiac arrest swine model. J Surg Res 2016;
201:327-33. doi:10.1016/j.jss.2015.11.015.
23 Boysen SR, Pang JM, Mikler JR, Knight CG, Semple HA,
Caulkett NA. Comparison of tranexamic acid plasma
concentrations when administered via intraosseous andintravenous routes. Am J Emerg Med 2017;35(2)227-33.
http://dx.doi.org/10.1016/j.ajem.2016.10.054.

MEDICATIONS/FLUIDS

The infusates listed below weredelivered via the IO route andreferenced in clinical literature:

•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Adenosine1-6,62
Albumin7,8
Alfentanil 9
Alteplase10,11,12
Aminophylline13
Amiodarone13,14,15,16
Ampicillin14,17
Anesthetic agents18,19,20
Antibiotics

17,21,22,23,59

Antitoxins24
Anti-meningococcal antitoxin25
Anti-pneumococcus serum25
Anti-tetanus serum26
Atracurium besylate9,27Atropine13,14,28,29
Aztreonam14
Benzylpenicillin (Penicillin G)59
Blood and blood
products7,13,14,18 26,29-33,59

•
•
•
•
•
•
•

Bretylium34
Calcium chloride14,32
Calcium gluconate35

•
•
•
•
•
•
•
•
•
•
•
•

Dexamethasone29,32
Dextran29
D5W9
D5 ½NS14
Dextrose 10%14
Dextrose 25%14
Dextrose 50%13,14
Diazepam34,43
Diazoxide29
Digoxin51
Diltiazem14
Diphenhydramine14
Dobutamine hydrochloride

14,21

Dopamine13,14,45
Ephedrine9
Epinephrine13,14,31,59
Etomidate13,14,46
Fentanyl13,14,47
Flucloxacillin (floxacillin)59
Fluconazole14
Flumazenil46
Fosphenytoin14
Furosemide13
Gentamicin7 14
Haloperidol37
Hartmann’s Solution

Cefazolin21(Compound Sodium Lactate

Cefotaxime22

Solution)29,48,59

Ceftriaxone14
Centruroids (Scorpion) Immune
F(ab1)2 (Equine) Injection(Scorpion Antivenom-trade:
Anascorp®)24,36

•
•

•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Cisatracurium besylate37
Contrast media29,38-42

•
•
•
•
•

Heparin14,15,29
Hydroxocobalamin46,49
Hydrocortisone19
Hydromorphone14
Hypertonic saline/dextran(7.5% NaCl/6% dextran)50

Insulin14,51
Isoprenaline9
Ketamine14,19,47,52,59
Labetalol37
Lactated Ringer’s Solution9,13,29
Levetiracetam14
Lidocaine13,14,29,30,56-58,60
Linezolid14
Lorazepam14,37
Magnesium sulfate14,37
Mannitol32
Methylprednisolone sodium
succinate14,37

•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Midazolam13,14,21,59
Mivacurium9
Morphine sulfate14,32,47,53,59
Nalbuphine9
Naloxone13,14
Neostigmine9,19
Norepinephrine13,14
Normal saline13
Ondansetron14
Pancuronium20,21
Paracetamol9
Penicillin21
Phenobarbital14
Phenylephrine14
Phenytoin14,32,54
Piperacillin14
Potassium chloride37
Promethazine13,14
Propofol30,59
Recombinant fVIIa59
Remifentanil9

60

61

MEDICATIONS/FLUIDS

•
•
•
•

7

Rocuronium13,14,30,52
Standard IV solutions13
Succinylated gelatin solution 4%(Gelofusine®)55•

8Kelsall AW. Resuscitation with intraosseous lines in neonatal
units. Arch Dis Child 1993;68:324-5.
Neuhaus D, Weiss M, Engelhardt T, et al. Semi-elective
intraosseous infusion after failed intravenous access in pediatric(suxamethonium)

9,13,27,43,52,59

•
•
•
•
•
•
•
•
•
•

1994;20(7):529-33.

9Succinylcholine

Alba RM, Ruiz Lopez MJ, Flores JC. Use of the intraosseousroute in resuscitation in a neonate. Intensive Care Med

Sodium bicarbonate

13,43

anesthesia. Pediatric Anesthesia 2010;20:168-71.
10 Landy C, Plancade D, Gagnon N, Schaeffer E, Nadaud J,

Sufentanyl46
Tenecteplase15,28

Favier JC. Complication of intraosseous administration ofsystemic fibrinolysis for a massive pulmonary embolism with

Thiamine13,14

cardiac arrest. Resuscitation 2012;83:e149-50. doi:10.1016/j.

Thiopental

resuscitation.2012.01.044.

27,32

Tobramycin sulfate14
Tranexamic acid18,61
Vancomycin14,17
Vasopressin

13,14

Vecuronium

14,28,32,59

Vitamin K 7

11 Northey LC, Shiraev T, Omari A. Salvage intraosseousthrombolysis and extra corporeal membrane oxygenation for
massive pulmonary embolism. J Emerg Trauma Shock 2015;
8:55-7.
12 Spencer TR. Intraosseous administration of thrombolytics for
pulmonary embolism. J Emerg Med 2013;45(6)e197-200.
http://dx.doi.org/10.1016/j.jemermed.2013.05.057.
13 Davidoff J, Fowler R, Gordon D, et al. Clinical evaluation of anovel intraosseous device for adults: prospective, 250-patient,

1

American Heart Association 2010 American Heart Association
guidelines for CPR and ECC. Part 14-Pediatric advanced life
support. Circulation 2010;122(3suppl.):S881-5.

2

American Heart Association. 2010 American Heart Association
guidelines for CPR and ECC: Part 8.2-Management of cardiac
arrest. Circulation 2010;122:S741-2.

3

American Heart Association. 2010 American Heart Association
guidelines for CPR and ECC: Part 8.2-Management of cardiac
arrest. Circulation 2010;122:S753.

4Friedman FD. Intraosseous adenosine for the termination of
supraventricular tachycardia in an infant. Ann Emerg Med
1996;28(3):356-8.

5

Getschman SJ, Dietrich AM, Franklin WH, Allen HD. Intraosseous
adenosine. As effective as peripheral or central venous
administration? Arch Pediatr Adolesc Med 1994(6);148:616-9.

6

Goodman IS. Intraosseous infusion is unreliable for adenosinedelivery in the treatment of supraventricular tachycardia.
Pediatr Emerg Care 2012;28(1):47-8.

multi-center trial. JEMS 2005;30(10):s20-3.
14 Dolister M, Miller S, Borron S, et al. Intraosseous vascularaccess is safe, effective and costs less than central venous
catheters for patients in the hospital setting. J Vasc Access
2013;14(3):216-24. doi:10.5301/jva.5000130.
15 Ruiz-Hornillos PJ, Marinez-Camara F, Elizondo M, et al.
Systemic fibrinolysis through intraosseous vascular access in
ST-segment elevation myocardial infarction. Ann Emerg Med
2011;57(6):572-4.
16 Santos D, Carron PN, Yersin B, Pasquier M. EZ-IO® intraosseous
device implementation in a pre-hospital emergency service: aprospective study and review of the literature. Resuscitation
2010;doi:10.1016/j.resuscitation.2012.11.006.
17 Joseph G, Tobias JD. The use of intraosseous infusions in theoperating room. J Clin Anesth 2008;20:469-73.
18 Lewis P, Wright C. Saving the critically injured trauma patient:a retrospective analysis of 1000 uses of intraosseous access.
Emerg Med J 2014;31(9):784. doi:10.1136/emermed-2014-203588.

MEDICATIONS/FLUIDS

19 Hamed RK, Hartmans S, Gausche-Hill M. Anesthesia through

34 Glaeser PW, Hellmich TR, Szewczuga D, Losek JD, Smith DS.

an intraosseous line using an 18-gauge intravenous needle forFive-year experience in prehospital intraosseous infusions inemergency pediatric surgery. J Clin Anesth 2013;25(6);447-51.

children and adults. Ann Emerg Med 1993;22(7):1119-24.

doi:10.1016/j.jclinane.2013.03.013.

35 Rosetti VA, Thompson BM, Miller J, Mateer JR, Aprahamian C.

20 Stewart FC, Kain ZN. Intraosseous infusion: elective use in

Intraosseous infusion: an alternative route of pediatricpediatric anesthesia. Anesth Analg 1992;75(4):626-9.

intravascular access. Ann Emerg Med 1985;14(9):885-8.

21 Goldstein B, Doody D, Briggs S. Emergency intraosseous

36 Hiller K, Jarrod MM, Franke HA, Degan J, Boyer LV, Fox FM.

infusion in severely burned children. Pediatr Emerg Care 1990;

Scorpion antivenom administered by alternative infusions. Ann

6:195-7.

Emerg Med 2010;56(3):309. doi:10.1016/j.annemergmed.

22 Moscati R, Moore GP. Compartment syndrome with resultant
amputation following intraosseous infusion. Am J Emerg Med
1990;8:470-1.
23 Tomar S, Gupta BA. Resuscitation by intraosseous infusion in
newborn. MJAFI 2006;62:202-3.
24 Mosier JM, Hiller K, Franke H, Degan J, Boyer LV. Scorpion
antivenom administered via alternative infusions. J Med Toxicol
2010;6:249.
25 Meola F. Bone marrow infusions as a routine procedure inchildren. J Pediatr 1944;25(1):13-6.
26 Heinild S, Sondergaard T, Tuvad F. Bone marrow infusion inchildhood. J Pediatr 1947;30(6):400-412.
27 Katan BS, Olshaker JS, Dickerson SE. Intraosseous infusion ofmuscle relaxants. Am J Emerg Med 1988;6(4):353-4.
28 Valdes M, Araujo P, de Andres C, Sastre E, Martin T. Intraosseousadministration of thrombolysis in out-of-hospital massive
pulmonary thromboembolism. Emerg Med J 2010;27(8):641-4.
doi:10.1136/emj.2009.086223.
29 Valdes MM. Intraosseous fluid administration in emergencies.
Lancet 1977;1(8024):1235-6.
30 Anson JA, Sinz EH, Swick JT. The versatility of intraosseous
vascular access in perioperative medicine: a case series. J Clin
Anesth 2015;27(1):63-7. http://dx.doi.org/10.1016/J.Jclinane.
2014.10.002.
31 Burgert JM. Intraosseous infusion of blood products andepinephrine in an adult patient in hemorrhagic shock. J Am
Assoc Nurse Anesth 2009;77(5):359-63.
32 Guy J, Haley K, Zuspan SJ. Use of intraosseous infusion in thepediatric trauma patient. J Pediatr Surg 1993;28:158-6.1.
33 Sherren PB, Burns B. Prehospital blood transfusion: 5-year
experience of an Australian helicopter emergency medical
service. Crit Care 2013;17(suppl 2):295.

2010.04.007.
37 Paxton JH, Knuth TE, Klausner HA. Proximal humerus
intraosseous infusion: a preferred emergency venous access.
J Trauma 2009;67:606-11.
38 Ahrens KL, Reeder SB, Keevil JG, Tupesis JP. Successful
computed tomography angiogram through tibial intraosseousaccess: a case report. J Emerg Med 2013;45(2):182-5.
doi:10.1016/j.jemermed.2012.11.091.
39 Cambray EJ, Donaldson JS, Shore RM. Intraosseous contrast
infusion: efficacy and associated findings. Pediatr Radiol 1997;
27:892–3.
40 Geller E, Crisci KL. Intraosseous infusion of iodinated contrast
in an abused child. Pediatr Emerg Care 1999;15(5):328-9.
41 Knuth TE, Paxton JH, Myers D. Intraosseous injection ofiodinated computed tomography contrast agent in an adultblunt trauma patient. Ann Emerg Med 2011;57(4):382-6.
42 Winkler M, Talley C, Woodward C, et al. The use of intraosseous
needles for injection of contrast media for computed tomographic
angiography of the thoracic aorta. J Cardiovasc Comput Tomogr
2017;11(3):203-7. http://dx.doi.org/10.1016/j.jcct.2017.03.001.
43 McNamara RM, Spivey WH, Unger HD, Malone DR. Emergency
applications of intraosseous infusion. J Emerg Med 1987;5:
97-101.
44 Tarrow Ab, Turkel H, Thompson Ms. Infusions via the bonemarrow and biopsy of the bone and bone marrow. J Anesthesiol
1952;13(5):501-9.
45 Berg RA. Emergency infusion of catecholamines into bonemarrow. Am J Dis Child 1984;138(9):810-1.
46 Gazin N, Auger H, Jabre P, Et Al. Efficacy and safety of the EZ-IO®
intraosseous device: Out-of-hospital implementation of amanagement algorithm for difficult vascular access. Resuscitation
2011;82(1):126.

62

63

PAIN MANAGEMENT FOR IO INFUSION

47 Aliman AC, Piccioni Mde A, Piccioni JL, Oliva JL, Auler Junior

60 Gillum L, Kovar J. Powered intraosseous access in the

JO. Intraosseous anesthesia in hemodynamic studies in children

prehospital setting: MCHD EMS puts the EZ-IO® to the test.

with cardiopathy. Rev Bras Anestesiol 2011;61(1):41-9.

JEMS 2005;30:S24-6.TS

48 Gunz FW, Dean RFA. Tibial bone marrow transfusions ininfants. Br Med J 1945;1(4389):220–1.
49 Fortin JL, Capellier G, Manzon C, Giocanti J, Gall O. Intraosseousadministration in the acute treatment of cyanide poisoning.
Burns 2009;35s:S15-16.
50 Chavez-Negrete A, Majluf Cruz S, Frati Munari A, Perches A,

61 Strong D, Powell E, Tilney PVR. A 20 year-old male withhemorrhagic shock. Air Med J 2016;35(1):8-11. http://dx.doi.
org/10.1016/j.amj.2015.10.003.
62 Helleman K, Kirpalani A, Lim R. A novel method of intraosseous
infusion of adenosine for the treatment of supraventriculartachycardia in an infant. Pediatri Emer Care 2017;33:47-48.

Arguero R. Treatment of hemorrhagic shock with intraosseousor intravenous infusion of hypertonic saline dextran solution.
Eur Surg Res 1991;23(2):123-9.
51 Tarrow AB, Turkel H, Thompson MS. Infusions via the bonemarrow and biopsy of the bone and bone marrow. J Anesthesiol

Pain Management for
IO Infusion

1952;13(5):501-9.
52 Barnard EBG, Moy RJ, Kehoe AD, Bebarta VS, Smith JE. Rapid
sequence induction of anesthesia via the intraosseous route: aprospective observational study. Emerg Med J 2014;doi:10.1136/
emermed-2014-203740.
53 Von Hoff DD, Kuhn JG, Burris HA, Miller LJ. Does intraosseousequal intravenous? A pharmacokinetic study. Am J Emerg Med
2008;26:31-8.
54 Walsh-Kelly CM, Berens RJ, Glaeser PW, Losek JD. Intraosseous
infusion of phenytoin. Am J Emerg Med 1986;4(6):523-4.
55 Chatterjee DJ, Bukunola B, Samuels TL, Induruwage L, Uncles

While the discomfort associated with IO insertionis variable, pain associated with IO infusion underpressure can be more severe.1 Consider slow
administration of two percent (2%)* preservativefree and epinephrine-free lidocaine given via
syringe into the IO catheter as a local (within the
medullary space)** anesthetic for patients responsive
to pain. Two percent (2%)* preservative-free and

DR. Resuscitation in massive obstetric haemorrhage using anepinephrine-free lidocaine (sometimes referred to as

intraosseous needle. Anaesthesia 2011;66:306-10. doi:10.1111/“cardiac lidocaine”) has been shown to be effective

j.1365-2044.2011.06629.x.
56 Ong ME, Chan YH, Oh HH, Ngo AS. An observational
prospective study comparing tibial and humeral intraosseousin limiting or alleviating IO infusion pain. Lidocaine
administered via the IO route for anesthetic effectaccess using the EZ-IO®. Am J Emerg Med 2009;27:8-15.

should be delivered slowly into the catheter so as

57 Waisman M, Waisman D. Bone marrow infusion in adults.

to remain in the IO space long enough to achieve

J Trauma 1997;42(2):288-93.
58 Frascone RJ, Jensen JP, Kaye K, Salzman JG. Consecutive fielda local anesthetic effect prior to administering thesaline flush.

trials using two different intraosseous devices. Prehosp Emerg
Care 2007;11:164-71.TS
59 Cooper BR, Mahoney PF, Hodgetts TJ, Mellor A. Intraosseousaccess (EZ-IO®) for resuscitation: UK military combat
experience. JR Army Med Corps 2007;153(4):314-6.

A 2016 abstract noted that the use of additional
analgesics may be an effective alternative to
lidocaine alone and mitigate the need for repeat
lidocaine dosing.2

PAIN MANAGEMENT FOR IO INFUSION* 2% preservative-free and epinephrine-free lidocaine may not be
available globally; refer to total dose in milligrams.
** Locally administered into the catheter for anesthesia within thedemonstrates the proximal humerus may be apreferred IO site for conscious patients.

medullary space for IO infusion pain.

A volunteer study done in 2016 compared 2%

Conscious Patients/Lidocaine Dosing

preservative-free and epinephrine-free lidocaine

Review manufacturer’s lidocaine instructions for use

doses of 40 mg followed by a flush, followed byprior to administration and observe recommended

placebo or an additional 20 mg dose, in the sternum

cautions/ contraindications to using 2% preservative-

and proximal humerus sites. This study indicatedfree and epinephrine-free lidocaine. Teleflex does

the second dose of 20 mg may be optional in the

not manufacture lidocaine. A number of articles

proximal humerus.12

in the literature describe clinical experience withlidocaine administration for IO infusion in patients

Lidocaine and appropriate dosages must be

responsive to pain.1-12 These cited sources document

prescribed by a qualified prescriber.

initial lidocaine doses ranging from 20-80 mg, withvarying doses for maintenance. For additional

Techniqueinformation visit: http://www.eziocomfort.com.

Consider anesthetic for adult patients responsive
to pain:

A 2010 article reported the combined results of•Observe recommended cautions/

two studies examining pain management with IO

contraindications to using 2%* preservative-

vascular access.1 These volunteer studies using thefree and epinephrine-free lidocaine(intravenous lidocaine)

humerus and tibia demonstrated that less pressure* or available concentration of intravenous lidocaine

was required to infuse through the humerus than
the tibia route, and demonstrated a direct correlation
between infusion pressure and pain level (i.e.

considering proper volume adjustments.

•

director, treating physician, or institutional

increased pain with greater infusion pressures).
During the 90-minute observation period in the tibial
study, eight of ten volunteers who had previously
received 100 mg lidocaine required an additional
20 mg lidocaine to keep the IO infusion pain level
below five (on a scale of 0-10). No volunteers in thehumeral study, who had previously received 60 mg
lidocaine, required additional lidocaine dosing tokeep pain levels below five. This article

Confirm lidocaine dose with your medical
protocol•Prime EZ-Connect® Extension Set
with lidocaine– Note that the priming volume of the
EZ-Connect® Extension Set is approximately
1.0 mL– If primed with 2% preservative-freeepinephrine-free lidocaine, this prime
volume will be approximately 20 mg

64

65

PAIN MANAGEMENT FOR IO INFUSION•••

Slowly infuse lidocaine (typically 40 mg) into•

the IO catheter over 120 seconds (two minutes)< 1.0 mL), consider administering by gently

Allow lidocaine to dwell in IO space 60 seconds

attaching syringe directly to needle hub (prime(one minute)

EZ-Connect® Extension Set with normal saline)

Flush the IO catheter with 5-10 mL of•

normal saline•

Slowly administer an additional 20 mg of
Repeat PRN for pain•

Allow lidocaine to dwell in IO space 60 seconds(one minute)•Consider systemic pain control for patients not
responding to IO lidocaine

Slowly infuse lidocaine IO over 120 seconds(two minutes)

lidocaine IO over 60 seconds (one minute)••For small doses of lidocaine (e.g. < 20 mg or

Flush the IO catheter with 2-5 mL of
normal saline•

Slowly administer subsequent lidocaine (halfthe initial dose – 0.25 mg/kg) IO over 60

Consider anesthetic for infants and children
responsive to pain:•

Observe recommended cautions/contraindications to using 2%* preservative-

seconds (one minute)••Repeat PRN for pain
Consider systemic pain control for patients not
responding to IO lidocaine

Pediatric Pain Management Recommendation

free and epinephrine-free lidocaine(intravenous lidocaine)

Figure 26* or available concentration of intravenous lidocaine
considering proper volume adjustments.

•

Confirm lidocaine dose with your medical
director, treating physician, or institutional
protocol– Typical initial dose is 0.5 mg/kg, not to

2% Preservative-Free and Epinepherine-Free Lidocaine
Adults: Typically 40 mg
Infant/Child: Typically 0.5 mg/kg (NOT to exceed 40 mg)

Lidocaine
Initial Dose
120 Seconds

exceed 40 mg•

with lidocaine– If primed with 2% preservative-freeepinephrine-free lidocaine, this prime
volume will be approximately 20 mg

Lidocaine½ Initial Dose
60 Seconds

EZIOComfort.com– Note that the priming volume of the
1.0 mL

Rapid
Flush

≥ 4 Minutes Total Time

Prime EZ-Connect® Extension Set

EZ-Connect® Extension Set is approximately

Dwell
60 Seconds

Observe cautions/contraindications for lidocaine, confirm dose per institution

Observe cautions/contraindications for lidocaine,confirm dose per institution.
Disclaimer
Selection and use of any medication, including lidocaine,
given IV or IO is the responsibility of the treating

PEDIATRICS: NEWBORNS, INFANTS, CHILDREN, AND ADOLESCENTS

physician, medical director, or qualified prescriber,

9

prehospital setting: MCHD EMS puts the EZ-IO® to the test.

and is not an official recommendation of Teleflex.
The information provided here is a summary of
information found in the cited reference materials.

Gillum L, Kovar J. Powered intraosseous access in the
JEMS 2005;30:S24-6.TS

10 Dolister M, Miller S, Borron S, et al. Intraosseous vascularaccess is safe, effective and costs less than central venous

This information is not intended to be a substitute forcatheters for patients in the hospital setting. J Vasc Accesssound clinical judgment or your institution’s treatment

2013;14(3):216-24. doi:10.5301/jva.5000130.TS

protocols. Teleflex is not the manufacturer of lidocaine.

11 Anson JA, Sinz EH, Swick JT. The versatility of intraosseous
vascular access in perioperative medicine: A case series. J Clin

Users should review the manufacturer’s instructions orAnesth 2015;27(1):63-7. http://dx.doi.org/10.1016/j.jclinane.

directions for use and be familiar with all indications,side effects, contraindications, precautions, and2014.10.002.
12 Montez D, Puga T, Davlantes C, Philbeck T. IO infusion pain
mitigation in the sternum and proximal humerus: establishingwarnings prior to administration of lidocaine or anya regimen. Crit Care Med 2016;44(12):154.TS

other medication. Teleflex disclaims all liability for theapplication or interpretation of this information in the
medical treatment of any patient.
1

Philbeck TE, Miller LJ, Montez D, Puga T. Hurts so good;easing IO pain and pressure. JEMS 2010;35(9):58-69.TS

2

Davlantes C, Puga T, Montez D, Philbeck T, Miller L, DeNoia E.
48 hour dwell time for intraosseous access: A longer-term
infusion using a temporary solution. Crit Care Med 2016;

defines the pediatric population as being fromOng MEH, Chan YH, Oh JJ, Ngo AS-Y. An observational,

newborn to 21 years of age using four pediatricprospective study comparing tibial and humeral intraosseous

subgroups. The FDA recognizes that the descriptions

access using the EZ-IO®. Am J Emerg Med 2009;27:8-15.TS
4

Waisman M, Waisman D. Bone marrow infusion in adults.
J Trauma 1997;42(2):288-93.

5

Paxton JH, Knuth TE, Klausner HA. Proximal humerus
intraosseous infusion: a preferred emergency venous access.
J Trauma 2009;67(3):606-11.TS

6

Frascone RJ, Jensen JP, Kaye K, Salzman JG. Consecutive fieldtrials using two different intraosseous devices. Prehosp Emerg
Care 2007;11:164-71.TS

7

Miller L, Kramer GC, Bolleter S. Rescue access made easy. JEMS
2005;30:S8-18.TS

8

The U.S. Food and Drug Administration (FDA)

44(12):140.

TS

3

Pediatrics: Newborns,
Infants, Children,
and AdolescentsDavidoff J, Fowler R, Gordon D, et al. Clinical evaluation of aare somewhat arbitrary and that weight, body size,
physiological development, neurological development, and neuromuscular coordination may often be
more appropriate indicators than chronological age.

•
•
•
•

Birth to 1 month of age. . . . . . . . Newborn> 1 month to 2 years of age. . . . . Infant> 2 to 12 years of age. . . . . . . . . . Child> 12 to 21 years of age. . . . . . . . . Adolescent

For the purpose of describing pediatric patients innovel intraosseous device for adults: prospective, 250-patient,

relationship to IO vascular access, the above sub-multi-center trial. JEMS 2005;30:S20-3.

groups will be used. For IO vascular access devices,TS

adolescents are usually considered adults.

66

67

PEDIATRICS: NEWBORNS, INFANTS, CHILDREN, AND ADOLESCENTS

http://www.fda.gov/downloads/MedicalDevices/

insertion site and for most adult humeral insertions.

DeviceRegulationandGuidance/GuidanceClinical judgment should be used to determine

Documents/ucm089742.pdf (Accessed 7/25/2017)

appropriate needle set selection based on patient
anatomy, insertion site, weight, and tissue depth.

EZ-IO Device: Indications in
Pediatric Patients

Just as a small adult patient may require a shorter

The EZ-IO Device is indicated for patients weighing

catheter. The EZ-IO® Catheter is marked with a

3 kg or over. The EZ-IO® System provides

black line approximately 5 mm from the hub. Black

intraosseous access in the proximal tibia, distallines on each catheter function as depth measuring

tibia and humeral head (proximal humerus) of adult

guides to help identify if the needle will be longand pediatric patients, and the distal femur inenough to seat properly in the medullary space bypediatric patients when intravenous access is

identifying soft tissue depth (see Figure 27 below).

difficult or impossible to obtain in emergent,

If the EZ-IO® Needle Set is inserted through the softurgent, or medically necessary cases for up to 24

tissue and does not reach the bone or a black markhours (U.S.) and 72 hours (EU).

is not visible above the skin, a longer needle set or®

®

length catheter, an obese child may require a longer

alternate site should be chosen prior to penetration

Can a 25 mm or 45 mm Needle Set Be
Used in a Pediatric Patient?

of the cortex.

The EZ-IO® Needle Sets do not have “adult” or

The ability to control insertion depth of the needle“pediatric” designations. Each needle set is indicated

set tip into the target bone is necessary for safewith guideline weight designations.* (see soft tissue

and effective intraosseous access. The depth ofdepth discussion on page 68) The 25 mm needle set

penetration is determined by sensing when theis indicated for 3 kg or over. The 45 mm needle set

needle set has penetrated through the dense cortex

may be considered when the patient’s weight is 40

and has entered the softer medullary cavity withkg or over or there is excessive tissue overlying thecancellous bone. This endpoint is recognized by the

Figure 27

5 mm

PEDIATRICS: NEWBORNS, INFANTS, CHILDREN, AND ADOLESCENTS“pop” or “give” that is felt when the needle reaches“pop” is felt, indicating entry into medullary space. A

the target area. With the exception of adult proximal

2010 study with a power-driven IO device confirmed

humerus insertions, routinely inserting the needle

a high reliability in discerning accurate needle set

set to the hub is not recommended technique,placement by tactile feedback (in models designed toespecially in pediatric patients. If the needle ismimic bone density differences).1

inadvertently advanced past the target area, it iscortex which allows the operator sufficient time

Is There a Risk of Over-Penetration with the
EZ-IO® Device?

to stop insertion before the opposite cortex is

Penetration of the IO needle set through the posterior

breached. The risks associated with an insertion

cortex of the bone is a possible complication, butthat is either too shallow or too deep (through the

avoidable with selection of appropriate needle set

opposite cortex) are similar. Proper technique that

length and proper insertion technique. As with alluses the black lines, tactile feedback technique, thevascular access devices, diligent placement

placement confirmation steps listed in the Instructions

confirmation, reassessment of the infusion, site,

For Use (IFU), and diligent reassessment mitigate

and limb will assist with reducing risk in cases of

those risks.

potential misplacement.

* Soft tissue depth over insertion sites can varydepending on individual anatomical characteristics.

Is Compartment Syndrome of Concern inPediatric Patients?

Therefore, the needle length required to reach theYes. Compartment syndrome is a serious

intraosseous space can vary from one patient tocomplication that can result if a large infiltration

the next even if they fall within the same age

and/or extravasation goes undetected. The IO

group and/or weight and height range. Needle set

insertion site should be monitored frequently forselection starts with the general weight ranges but

any signs of extravasation or infiltration.

possible to “feel” the needle tip hitting the distal

ultimately, the true measurement can be found by
confirmation steps to further validate correct

What is the Risk of Injury to the Epiphyseal(Growth) Plate in Pediatric Patients?

insertion depth. [See Selection of Appropriate

Several clinical and preclinical studies have

Insertion Site and Needle Set, page 29]

examined potential damage to the growth plateuse of the black line, and post-insertion placement

and reported no cases of impaired growth or boneIn Newborns, Infants, and Children, How
Deep Should the IO Needle Be Inserted?

abnormalities in the literature as a result of IO

Engage the driver trigger and apply moderate, steadyof IO Access on Growth Plates and Bone Repair forpressure. Release trigger when sudden “give” orspecific studies and in-depth discussion, page 53]

insertion through the epiphyseal plate. [See Effects

68

69

PEDIATRICS: NEWBORNS, INFANTS, CHILDREN, AND ADOLESCENTS

What Can Be Done to Manage IO Infusion
Pain in Pediatrics?

the application or interpretation of this information in
the medical treatment of any patient.

Two percent (2%**) intravenous preservative-free andas cardiac lidocaine) has been shown to be effective

How Much “Dead Space” Is in the EZConnect® Extension Set and IO Catheters?

in limiting or alleviating IO infusion pain and may

The approximate volume of the EZ-Connect®

be considered. Lidocaine administered via the IO

Extension Set is 1.0 mL. The dead space volume ofroute for infusion pain should be administered very

the 15 mm EZ-IO® Catheter itself contains 0.03 mL;

slowly (over 60-120 seconds) so as to remain in thea 25 mm catheter contains 0.045 mL; a 45 mm

IO space long enough to achieve a local anesthetic

catheter contains 0.07 mL. These volumes must be

effect, rather than immediately entering the vascularfactored into dosing requirements for pediatriccirculation. More information is available at:patients. The EZ-Connect® Extension Set mustwww.eziocomfort.com. [See Pain Management foralways be primed prior to attaching it to the EZ-IO®

IO Infusion for specific studies and in-depth

Catheter hub.

epinephrine-free lidocaine (sometimes referred to

discussion, page 63]** 2% intravenous preservative-free and epinephrine-free lidocaine
may not be available globally; refer to total dose in milligrams.

Disclaimer
Selection and use of any medication, including lidocaine,
given IV or IO is the responsibility of the treating
physician, medical director, or qualified prescriber
and is not an official recommendation of Teleflex.
The information provided here is a summary of
information found in the cited reference materials.
This information is not intended to be a substitute forsound clinical judgment or your institution’s treatment
protocols. Teleflex is not the manufacturer of lidocaine.
Users should review the manufacturer’s instructions
or directions for use and be familiar with allindications, side effects, contraindications, precautions,and warnings prior to administration of lidocaine or
any other medication. Teleflex disclaims all liability for

For Infants and Small Children, Should
the EZ-IO® Catheter Be Secured in Any
Special Manner?
Yes. The EZ-Stabilizer® is strongly recommended forall patients, but particularly for infants, due to softer,
thinner bones in this population. The EZ-Stabilizer®
adhesive area can be cut for a better fit on smallerlimbs; and should never be placed circumferentiallyaround a limb. For further protection, stabilize
the limb with an effective method that limits thelikelihood of dislodgement such as an arm board
or splint.
1

Miller L, Philbeck T, Bolleter S, Garcia G. Tactile feedback
comparison of three types of intraosseous access devices forneedle insertion accuracy. Ann Emerg Med 2010;56(3):S133.TS

PEDIATRICS: NEWBORNS, INFANTS, CHILDREN, AND ADOLESCENTS

General Discussion of IntraosseousAccess in Pediatrics Including Literature
and Techniquethat achieved via the central venous route andrecommends it as a viable route for drug
administration during CPR.

The American Heart Association (AHA) and theEuropean Resuscitation Council (ERC) recognizes

A joint policy statement endorsed by multiple

IO access as a viable vascular access route for the

professional societies provided guidelines for care

pediatric population. The 2010 AHA guidelines forof children in the Emergency Department, included

Pediatric Advanced Life Support state: “IO accessa recommendation for IO equipment in adult andis a rapid, safe, effective, and acceptable route forpediatric sizes.3

vascular access in children. All intravenous
medications can be administered intraosseously,

Medical literature reflects several decades of IO use

including epinephrine, adenosine, fluids, bloodin pediatric patients. A majority of these references

products, and catecholamines.”1 AHA guidelines

cite the low rate of complications and efficacy of IO

also emphasize that providers should limit the time

vascular access in pediatrics. More information on

spent attempting to establish peripheral venous

pediatric IO use can be found in the bibliography

access in a critically ill or injured child. AHA

available at: http://www.teleflex.com/en/usa/ezio

supports IO or IV vascular access as the preferrededucation/documents/General_IO_Bibliography.pdf

route for drug delivery during CPR, and recommends
against central venous access as the initial route ofBrief Literature Review

vascular access during emergencies.

An early (1947) study of 495 pediatric patients
undergoing IO procedures emphasized its “great

The ERC recommends consideration of IO access foradvantage in pediatrics”.4 A 1986 article by Iserson

initial securement of vascular access if intravenous

et al. discussed successful utilization of IO access

access is difficult or impossible. For pediatricin ten pediatric patients, and described IO

patients in cardiac arrest or pre-arrest states inaccess as a safe, rapid method to gain access toseriously ill or injured pediatric patients, thevenous circulation.5

guidelines recommend vascular access by peripheral
IV or the IO route. In critically ill children if attempts

A 1990 New England Journal of Medicine review

at peripheral access are unsuccessful after one

stressed the relative safety of IO access and reported

minute, IO access should be established.2 The 2015

earlier findings of no lasting negative effects of IO

ERC guidelines reiterate that IO access is a rapid,

infusion on the bone, growth plates, and marrow

safe, and effective vascular access route; andelements.6 In 2011 the New England Journal ofnote that the onset of action and time to achieve

Medicine published an updated overview of pediatricadequate plasma drug concentrations are similar to

IO access concluding IO access “… is a reliable

70

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PEDIATRICS: NEWBORNS, INFANTS, CHILDREN, AND ADOLESCENTS

means of obtaining urgent vascular access innurses) reported feeling “comfortable” or “verychildren and is associated with low rates ofcomfortable” with the device, and recommended

reported complications.”

its use over a manual IO needle. Reported

7

complications included infiltration, slow flow rate,
A 2005 retrospective study demonstrated the safety

and needle dislodgement during transport.

and efficacy of IO needle/catheter placement during
pediatric critical care transport. Investigators

Overviews of pediatric IO vascular access, including

identified 47 patients requiring 58 IO placements;

three written by anesthesiologists describe cases

first attempt success rate was 78%. Complications

and support IO availability, training, and use in thewere noted in 12% of patients, all limited to local

pediatric population.7,12-20

8edema or infiltration. A second 2005 retrospective
study examined data from 129 pediatric major

Multiple pediatric case studies have been cited intrauma patients who received IO vascular access.

the literature. Unique cases include a 2010 case of

The authors noted that the relatively high mortality

a two year-old that received hypothermia via IO

rate (64%) was likely due to severity of injuries

access; a nine month old treated for suspected

and difficulty obtaining venous access. Investigators

cyanide poisoning with IO administeredconcluded IO access use is safe, simple, andhydroxocobalamin, and a sixteen month old that

effective, and suggested IO training for personnel

received scorpion anti-venom for severe distressinvolved with pediatric trauma resuscitation.

following a scorpion sting.21-23

In a 2008 retrospective study of 95 pediatricEffect on Epiphyseal (Growth) Platespatients, Horton and Beamer evaluated the safety

A 1990 New England Journal of Medicine review

and effectiveness of the EZ-IO Device in thisstressed the relative safety of IO access and reported

population. Successful insertion and infusion wason earlier findings of no lasting negative effects ofachieved in 94% of the patients; 77% achieved

IO infusion on the bone, growth plates, and marrowin one attempt. The authors reported four minor

elements.6 Lack of negative effect on the epiphyseal

complications (4.2%), but none significant. The study

plate subsequent to IO infusion has beenconclusions supported use of the EZ-IO Device fordemonstrated in several radiographic studies in thechildren in emergency situations.

pediatric population. Preclinical studies in swine

9

®

10

®

have supported similar conclusions. A 1947 clinicalA prospective study by Frascone examinedstudy designed to examine incidence of long-term

prehospital use of the EZ-IO Device in pediatricbone abnormalities during radiographic follow-up

patients. Successful insertion was achieved in 95%

in seventy-two pediatric patients who received IO

of patients.11 A majority of providers (paramedics,

insertion. No patient exhibited radiographic bone®

PEDIATRICS: NEWBORNS, INFANTS, CHILDREN, AND ADOLESCENTS

abnormality and bone growth was normal for allpressure is required for insertion. Due to softer,

patients in the study. Thirty-six of those patientssmaller pediatric bones, special care must be taken

were followed up for a year; eighteen were followed

during insertion to avoid both excessive pressure

for up to two years, and eighteen were followed

and recoil. “Recoil” occurs when the clinician feels

for over two years post-infusion. A 1997 study

the lack of resistance upon entry into the medullary

performed radiographic measurements of the tibias

space and inadvertently jerks back on the driver.*in pediatric patients twelve months after IO infusion.

Recoil may displace the needle set from theResults demonstrated no significant difference inmedullary space and prevent additional attempts

tibial lengths. In 2003, a clinical study of pediatricfor IO access at that site. Release trigger when

patients receiving IO infusions revealed nosudden “give” or “pop” is felt, indicating entry

radiographic differences in tibia width or length.

into medullary space. A 2010 study with a power-

The follow-up radiographs were performed on

driven IO needle confirmed a high reliability inaverage 29 months after infusion. A 2003 overview

discerning accurate needle set placement byarticle is also supportive of these findings. In 2004,

tactile feedback (in models designed to mimic

Baren’s summary discussed a study of 23 children

bone density differences).28

4

24

25

26

that received IO tibial infusions and concluded that
long-term growth abnormalities are unlikely in* Practice Tip: An EZ-IO® Device training techniquechildren after IO infusions.27

developed to avoid too much pressure and the reflex
of “recoil” includes practice insertions on a raw egg.

Site Selection and Landmarks

This assists with development of the ability to avoid

Identifying and locating appropriate landmarks isapplication of too much downward pressure by

essential to successful IO insertion. For step by“letting the driver do the work.” This training also

step insertion technique please see section titleddevelops the practice of keeping the driver in place“Technique and Training” specific to each insertion

once the needle set enters the egg shell.

site. [See “Selection of Appropriate Insertion Site
and Needle Set” on page 29]

Stabilization: After insertion of the EZ-IO® Catheter,
use the EZ-Stabilizer® dressing to secure the device

Summary of Insertion Technique (after
landmarks are located and generaltechnique for all sites)and prevent accidental dislodgement. The EZStabilizer® dressing can be cut to size, and“telescopes” to accommodate varying insertion
depths. Generally, the EZ-Stabilizer® dressing should

Insertion: Prior to deploying the driver, ensure at

not be placed circumferentially around an extremity.

least one black line is visible above the skin when

If an EZ-Stabilizer® dressing is unavailable, otherthe needle set is touching the bone. Gentle, steadymethods should be used to secure the device.

72

73

PEDIATRICS: NEWBORNS, INFANTS, CHILDREN, AND ADOLESCENTS

For further protection, we strongly recommend

attaching syringe directly to needle hub (prime

securing the leg with an arm board or splint; andEZ-Connect® Extension Set with normal saline)

the arm with an effective securement device to limit**2% intravenous preservative-free andpotential for dislodgement (such as a sling andepinephrine-free lidocaine may not be available

swathe or a shoulder immobilizer brace).

globally; refer to total dose in milligrams•More information is available at: www.ezio

Syringe Flush: Infants and small children will not

comfort.com/ezio-comfort.html#dosing-&-be able to accommodate the same syringe flushadministration [See also Pain Management forvolume and force as recommended for adults and

IO Infusion, page 63]

may require less force for both the syringe flush andinfusion of fluids. Clinical judgment should be used

Confirm Placement: Correct IO placement should beto determine an appropriate volume for the syringe

confirmed with the following methods:

flush and infusion pressure in pediatric patients, and•••will be dependent on the child’s condition, weight,
and size. A general flush volume recommendationis 2-5 mL for infants and small children. The flush
should generally not be done as rapid or as

Stability of catheter
Ability to aspirate blood or marrow*
Adequate flow rate

* An inability to aspirate is sometimes described after initial IO
catheter insertion. Inability to withdraw/aspirate blood from thevigorously as in an adult, because the pressure

catheter hub does not mean the insertion was unsuccessful.

generated could cause the needle to become

Consider attempting to aspirate after a small flush.

dislodged from the intended insertion site/depth,
since pediatric bones are much softer than that ofInfusion: Infants and children may require lessan adult.

infusion pressure (than adults) for adequate
flow rates.

Conscious Patients (or patients responsive topain): Consider the use of 2%** intravenous

Monitor Site: The IO insertion site and affected

preservative-free and epinephrine-free lidocaine

limb must be monitored frequently for extravasation(sometimes referred to as “cardiac lidocaine”) foror other problems such as an increase or new

anesthesia prior to the initial saline flush; prime thecomplaint of pain, inability to infuse, changes in

EZ-Connect® Extension Set with the appropriate

skin color, or anything that may indicate the IO

amount of lidocaine and factor in the priming dose

insertion site and infusion may be compromised.

in administration.
For additional guidance on IO use in infants and•For small doses of lidocaine (e.g. < 20 mg orchildren, please contact Teleflex Customer Support< 1.0 mL), consider administering by gently

at 1.866.479.8500 or +1.866.479.8500 out of thePEDIATRICS: NEWBORNS, INFANTS, CHILDREN, AND ADOLESCENTS

U.S., your local Teleflex representative or visit:
http://www.teleflex.com/ezioeducation.

15 Cullen PM. Intraosseous cannulation in children. Pediatr Crit
Care Med 2011;13(1):28-30.
16 Cleugh FM, Maconochie I. Management of the multiply injured

1

American Heart Association 2010 American Heart Association
guidelines for CPR and ECC. Part 14 - Pediatric advanced life
support. Circulation 2010;122(3 suppl.):S881-5.

2

Monsieurs KG, Nolan JP, Bossaert LL et al. European
Resuscitation Council guidelines for resuscitation 2015 Section
1. Executive summary. Resuscitation 2015;95:1-80.

3American Academy of Pediatrics. Joint policy statement –guidelines for care of children in the emergency department.
JEN 2013;39(2):116-27.

4

Heinild S, Sondergaard T, Tuvad F. Bone marrow infusion inchildhood. J Pediatr 1947;30:400-12.

5

child. Paediatrics and Child Health 2012;23(5):194-9.
17 Anson JA, Sinz EH, Swick JT. The Versatility Of Intraosseous
Vascular Access In Perioperative Medicine: A Case Series.
J Clin Anesth 2015;27(1):63-7. http://dx.doi.Org/10.1016/J.
Jclinane.2014.10.002.
18 Weiser G, Poppa E, Katz Y, Bahouth H, Shavit I. Intraosseous
blood transfusion in infants with traumatic hemorrhagic
shock – a case report and review of the literature. Am J Emerg
Med 2013;31(3):640e3-4. http://dx.doi.org/10.1016/j.ajem.
2012.10.036.
19 Chansa E, Kansen K, Gustafsson B. An intraosseous bloodtransfusion in a critically ill child [Une transfusion sanguine

Iserson KV, Criss E. Intraosseous infusions: a usable technique.

par voie intraosseuse chez un enfant gravement malade]. Afr J

Am J Emerg Med 1986;4(6):540-2.

Emerg Med 2013. http://dx.doi.org/10.1016/j.afjem.2013.05.003.

6

Fiser DH. Intraosseous infusion. NEJM 1990;322(22):1579-81.

7Nagler J, Krauss B. Intraosseous catheter placement inresuscitation in a pediatric patient with ebola virus disease.

children. NEJM 2011;364(8):e14-8.

J Emerg Med 2015;49(6):962-4. http://dx.doi.org/10.1016/j.

8

Fiorito BA, Mirza F, Doran TM, Oberle AN, et al. Intraosseousaccess in the setting of pediatric critical care. Pediatr Crit Care
2005;6(1):50-3.

9Smith R, Davis N, Bouamra O, Lecky F. The utilisation of
intraosseous infusion in the resuscitation of paediatric major
trauma patients. Injury 2005;36(9):1034-8.

10 Horton MA, Beamer C. Powered intraosseous insertion
provides safe and effective vascular access for pediatricemergency patients. Pediatr Emerg Care 2008;24(6):347-50.
11 Frascone RJ, Jensen J, Wewerka SS, Salzman JG. Use of thepediatric EZ-IO needle by emergency medical services®

providers. Pediatr Emerg Care 2009;25:329-32.TS
12 Tobias JD, Ross AK. Intraosseous infusions: A review for the
anesthesiologist with a focus on pediatric use. Anesth Analg
2010;110(2):391-401.
13 Neuhaus D, Weiss M, Engelhardt T, et al. Semi-elective
intraosseous infusion after failed intravenous access inpediatric anesthesia. Pediatric Anesthesia 2010;20:168-71.
14 Neuhaus D. Intraosseous Infusion in elective and emergency
pediatric anesthesia: when should we use it?. Curr Opin

20 Paterson ML, Callahan CW. The use of intraosseous fluid

jemermed.2015.06.010.
21 Truhlar A, Skulec R, Rozsival P, Cerny V. Efficient prehospitalinduction of therapeutic hypothermia via intraosseous infusion.
Resuscitation 2010;81(2):262-3.
22 Hiller K, Jarrod MM, Franke HA, Degan J, Boyer LV, Fox FM.
Scorpion antivenom administered by alternative infusions. Ann
Emerg Med 2010;56(3):309. doi:10.1016/j.annemergmed.2010.
04.007.
23 Fortin JL, Capellier G, Manzon C, Giocanti J, Gall O. Intraosseousadministration in the acute treatment of cyanide poisoning.
Burns 2009;35S:S15-16.
24 Fiser RT, Walker WM, Seibert JJ, et al. Tibial length following
intraosseous infusion: a prospective, radiographic analysis.
Pediatr Emerg Care 1997;13(3):186-8.
25 Claudet I, Baunin C, Laporte-Turpin E. Long-term effects on
tibial growth after intraosseous infusion: a prospective,
radiographic analysis. Pediatr Emerg Care 2003;19(6):397-401.
26 LaRocco BG, Wang HE. Intraosseous infusion. Prehosp Emerg
Care 2003;7:280-5.
27 Baren J. Are powered intraosseous insertion devices safe andAnaesthesiol 2014;27(3):282-7. doi:10.1097/ACO.

effective in children? Journal Watch Emergency Medicine.

0000000000000069.

Aug 2008.

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28 Miller L, Philbeck T, Bolleter S, Garcia G. Tactile feedback
comparison of three types of intraosseous access devices forneedle insertion accuracy. Ann Emerg Med 2010;56(3):S133.TS

Laboratory Analysis/
Blood Sampling
Are Blood Specimens Drawn Via the IO
Route Adequate for Laboratory Analysis?

The following laboratory values have produced
significant correlation between IO and IV values inhuman studies:

•
•
•
•
•

GlucoseHemoglobin
Hematocrit
BUN

•
•
•
•

Total protein
Red blood cell countAlbumin
ChlorideCreatinine

The most recent clinical studies in healthy volunteers

The following laboratory values have shown mixed

examining IO compared to venous laboratory values

results in producing significant correlation between

demonstrated significant correlation for many

IO and IV values (some values were clinicallycommonly ordered lab studies, with some exceptions

similar, but not statistically correlated):

noted. In these studies, IO blood proved to bereliable for:••Red blood cell countHemoglobin andhematocrit••

GlucoseBlood urea nitrogen

•
•
•
•
•

Creatinine
Chloride
Total protein
AlbuminLactate

(BUN)

•
•
•
•
•
•
•
•

CO2
Potassium
SodiumCalcium
Platelet countPhosphorus
Uric acid/urea
Total bilirubin

•
•
•
•
•
•
•
•

SGOT
LDH
Alkaline phosphatase
BicarbonatepH
pO2 (venous values)
pCO2 (venous values)
Base excess

Significant correlation was not achieved for sodium,

IO and IV values for white blood count do notpotassium, CO2, calcium, platelets or white bloodcorrelate in any known study.

cell count. However, sodium and potassium values
Blood Sampling from IO Access on this page forLaboratory Analysis/Blood Sampling fromIO Accessresearch details.]

Based on preclinical and clinical evidence

were clinically similar. [See Laboratory Analysis/comparing IO and venous or arterial sources a
From a review of all known published clinical literature

number of common laboratory values correlate

examining IO compared to venous laboratory values,

well; other values show clinical similarity without

the list below summarizes aggregate results of IO

statistically significant correlation, therefore caution

correlation with IV blood values.

should be exercised with their interpretation.
Certain point of care analyzers have been studied

LABORATORY ANALYSIS/BLOOD SAMPLING

with acceptable results. Check with your laboratory

A prospective study compared IO and venous

for IO specimen processing capabilities. For morelaboratory values obtained from a point-of-care

information regarding IO lab analysis, refer to:

analyzer (i-STAT) in 20 children. IO blood specimens

www.teleflex.com/ezioeducation.

were collected from the iliac crest; 2 mL werediscarded before the sample was collected forSummary and Recommendations

analysis. Results showed differences between

Overall review of the clinical evidence suggests thatvenous and IO sample were clinically acceptableearly in the resuscitation process, blood gas values

for pH, base excess, sodium, ionized calcium, andderived from IO blood may be used to assess central

glucose in hemodynamically stable patients.

venous acid-base status, and that a number ofAuthors concluded that analysis of IO samples

blood count and chemistry values will equal venous

with a bedside point-of-care analyzer is feasible

samples. Other values will approximate venous

and in emergency situations may be useful tovalues; few will not correlate. IO samples should be

guide treatment.2

used with caution after resuscitation efforts beyond
From a series of healthy volunteer studies conducted

the immediate phase. The work of Brickman et al.

in 2012 and 2013, Montez et al. compared IO andprovides evidence that blood typing and screening
can be done accurately and reliably using IO blood.

venous blood to determine if there is a clinical

For a tabular summary of laboratory values thatsimilarity and/or correlation between samples

have produced statistically significant correlationfrom the two sources for serum lactate level. From

between IO and IV in human studies, refer toeach arm of 15 study subjects, peripheral venous

previous section.

specimens were collected, followed by a proximal

9

humerus IO blood sampling. Each IO and venous

Clinical Studies

sample was analyzed for lactate levels, using the

A small prospective pilot study by Tallman was

I-Stat point-of-care analyzer. There was a positive

published in 2016 using a point-of-care analyzer tocorrelation between IO blood lactate and venous

compare samples from IO and venous samples inblood lactate (R2 = 0.623, n = 23, p < 0.001).

the emergency department. With consideration of

Investigators concluded that lactate levels obtained

the study limitations (small subject numbers,from IO blood appear comparable to lactate levels

inability to obtain venous samples from somefrom venous blood, and those values are reflectedpatients, limited testable analytes amongst thosein positive correlation. The subjects in this study

noted) investigators felt the results were clinicallywere healthy and results may not accurately reflect

acceptable for pH, bicarbonate, sodium and basethe results that may be seen in patients who areexcess, and possibly lactic acid.

septic or have other illnesses and injuries. Further

1

investigation is needed in patients to determine if

76

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LABORATORY ANALYSIS/BLOOD SAMPLING

the relationship between IO and IV values continues

routine blood analysis in pediatric patients.6 The

to exist in non-healthy patients.3

laboratory values for hemoglobin, hematocrit,sodium, urea, creatinine, calcium were considered

A 2009 study (unpublished) in healthy volunteers

to be clinically similar. Potassium levels were elevatedexamined the reliability of IO cardiac enzyme andin most samples, and study authors recommended

blood gas values. The study compared venous“great caution should be exercised in theirand IO samples of two common cardiac enzymes

interpretation.” Authors also recommended that

(Troponin-I and creatine phosphokinase), and also

blood samples obtained intraosseously may givecompared venous, arterial and IO samples for blooda useful guide to peripheral blood levels of somegas analyses. Values for IO blood gases fell between

hematological and biochemical values, but cautioned

arterial and venous blood sample values. Results

the values should be “interpreted with care.”4

demonstrated a significant correlation between
venous and IO blood for creatine phosphokinase,In 1994, Ummenhofer and associates found bone

and for pH and base excess. Arterial and IO blood

marrow and venous blood samples to be similar incorrelated well for pCO2. Correlation analysis was

regard to hemoglobin, sodium, chloride, glucose,

not possible for Troponin-I. However, results werebilirubin, BUN, creatinine, pH, and bicarbonate in

identical or clinically similar for seven of the

30 children with blood disorders.7 IO blood wasten samples.

also moderately accurate for hematocrit, potassium,and total protein, but not for alkaline phosphatase,

A study using adult volunteers conducted in 2009

aspartate aminotransferase, alanine aminotransferase,

examined the relationship between IO and venous

thrombocytes, pCO2, pO2, and leukocytes.

blood samples for complete blood count andchemistry profile.5 Researchers concluded that IO

In a 1991, 15-patient study, Grisham and Hastingsand IV laboratory values had statistically significant

reported that bone marrow aspirate from the iliac

correlation for many commonly ordered lab studies,

crest was a reliable source for blood gas and serumwith some exceptions noted. The IO space proved

chemistries.8 In a 28-patient clinical trial theto be a reliable source for red blood cell count,following year, Brickman et al. compared IO

hemoglobin and hematocrit, glucose, blood urea

aspirates against standard peripheral IV blood

nitrogen, creatinine, chloride, total protein, andwith regard to ABO and Rh typing.9 Researchers

albumin. No statistically significant correlation was

concluded that IO blood can be used for accurateachieved for sodium, potassium, CO2, calcium,and reliable typing and screening of blood. Their

platelets or white blood cell count. However, sodium

study did not address whether IO blood can be usedand potassium values were clinically similar. A 2000

for cross-matching.

study by Hurren examined IO blood samples for

LABORATORY ANALYSIS/BLOOD SAMPLING

Preclinical Studies

A 1999 study by Abdelmoneim et al. examined

In 1986, Unger and associates reported thatthe acid-base status of blood samples from IO andelectrolytes, calcium, glucose, BUN, and creatinine

mixed venous sites during prolonged CPR and drug

were not different in bone marrow and venous blood

infusions in swine.15 The investigators found noin swine.10 In a 1989 canine study, Orlowski et al.

difference in pH and pCO2 levels during the first 15

compared blood laboratory values for IO, arterial,

minutes of CPR. However, this correlation did not

and venous samples. No significant differences were

continue during resuscitations of longer duration or

found among the three source sites for most blood

after bicarbonate infusion. Large volumes of saline

electrolytes, chemistry values, and hemoglobin.

infusion and the use of epinephrine did not affectResults for liver enzymes (lactate dehydrogenase,the association in resuscitation times underalkaline phosphatase) varied among the three sites.

15 minutes.

Blood gases were significantly different among
all sites, pH, pO2, pCO2, HCO3, and SpO2 were

In another 1999 swine study, Johnson et al. foundconsistently intermediate between arterial andno differences in sodium, potassium, magnesium,

venous samples, suggesting a possible correlationlactate, and calcium levels in IO aspirates versus

with arterialized capillary blood gases. In thecentral venous blood samples during the first five

1990s, Kissoon and associates conducted a series ofminutes of CPR.16 After 30 minutes, differencesswine studies to determine the relationship between

were noted in magnesium and potassium values,

IO and venous blood for determining acid-base

but the investigators observed no differences invalues. In a 1993 study the authors reported thatbiochemical (i.e. chemistry values) and hemoglobin

acid-base status of IO blood is similar to status ofvalues if no drugs were given though thecentral venous blood, and may be an acceptable

intraosseous site.

11

alternative to central venous blood gas values indetermining central acid-base status during CPR.11

In a 2011 preclinical study by Strandberg et al.,

In a 1994 study comparing pH and pCO2 values

IO and arterial blood samples were collected over aof samples simultaneously obtained from central

six-hour time period from the tibia of anesthetizedvenous and IO lines, researchers concluded thatswine and analyzed using an i-STAT device to

pH and pCO2 values were similar. In a 1997 study,

compare values. Results showed compliant values

Kissoon’s group compared the acid-base values

between IO and arterial blood for electrolytes,of blood obtained through the IO route and mixed

hemoglobin, pH, and pCO2. Lactate, base excess

venous blood. The authors concluded that IO blood(BE), PO2 and SO2 were less compliant. There weremay reflect local acidosis, yield lower pCO2 andhigh correlations between SO2 and PO2 although thehigher pH values than central venous blood aslevels in arterial blood were higher.17 The same

CPR progresses.14

investigator published a 2012 preclinical study with

13

78

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LABORATORY ANALYSIS/BLOOD SAMPLING

a similar design collecting blood samples fromto be compared from serial venous plasma,bilateral tibial intraosseous cannulae and an arterial

arterial plasma, and intraosseous aspirate

catheter over six hours using an i-STAT point of carespecimens collected hourly. Two milliliters of IO

analyzer. Authors noted analysis of intraosseous

aspirate were discarded before collecting each IO

samples with a handheld cartridge based system is

specimen for analysis. The levels of IO troponin I

convenient and should bypass the potential problem

increased during the first three hours of shock butwith bone marrow contents damaging conventional

then plateaued at a high level while the venous

laboratory equipment. For most variables, there

and arterial levels continued to increase. Authors

seemed to be some degree of systematic difference

concluded that troponin I can be analyzed in bone

between intraosseous and arterial results; and themarrow aspirates in a shock model and that thisdirection of the difference seemed to be predictable.

information may be useful in medical emergencies

Investigators concluded that cartridge based point

where cardiac damage is suspected to be involved.20

of care instruments appear suitable for the analysis
of intraosseous samples. The agreement between

In 2016 Eriksson compared arterial and intraosseous

intraosseous and arterial analysis seemed to be

derived biomarkers to determine if the results would

clinically useful. In another swine study, several ofcorrelate well enough over a period of six hours to

the same investigators sought to evaluate whether

consider use of IO derived blood when traditional

intraosseous blood samples can be used to measuresamples are difficult to obtain. Authors noted there

opioids, and if so, to determine the level ofwere no clinically relevant average differences

accuracy of those measurements. Blood samples

between IO and arterial samples for alanine

were drawn from bilateral tibial IO catheters andaminotransferase, alkaline phosphatase, aspartatefrom a central venous catheter for six hours. The

aminotransferase, creatinine kinase (CK), andmorphine levels in the CVC samples were higher

gamma-glutamyl transferase values; and IO bloodthan those drawn from the IO sites; and authors

may be good enough for initial estimates of these

postulated that morphine has low fat solubility andmarkers in emergencies. However the lactate

young swine marrow is rich in fat which may havedehydrogenase levels showed less correlation andcontributed to the difference in levels. Between IO

for certain tests, the precision of IO samples may

sites the variability between the two IO ports was

be limited.21

18

less than 10%. The authors concluded intraosseous
samples can be used for the analysis of morphine

In Strandberg’s 2016 swine study IO and venous

if an IV route is not available. Eriksson et al.

samples were analyzed for thromboelastography

conducted a preclinical study in which eight(TEG), prothrombin time (PT), activated partial

anesthetized swine were put into an induced septic

thromboplastin time (APTT), and fibrinogenshock state to allow troponin I level measurements

concentration. The IO samples were clinically

19

LABORATORY ANALYSIS/BLOOD SAMPLING

hypercoagulable, rendering some samples

chosen to stay similar to wait time recommendations

unevaluable; clinically relevant differences werein IV lab studies. Authors concluded that if IO

observed for APTT but not for PT and fibrinogen andvascular access is necessary, and POC samples

the TEG demonstrated a shortened reaction time.

requested for these specific lab values, the initial

The ability to use IO drawn blood for coagulation

specimen drawn from the IO catheter may be

22

studies may be limited. In 2016 a preclinical swine

considered for sampling. Also, if an IO infusion

model study was conducted to compare bloodof saline is occurring, a wait time of two minutes

samples drawn from a central venous catheter (CVC)

post-stopping the infusion may be adequate forto blood samples drawn from IO catheters. This pilot

analysis. For these analytes, IO specimen values

study had two objectives: determine how long an

were comparable to CVC values. Limitations include

infusion must be stopped before drawing an IO

swine model, sample size, and infusion of one

specimen for analysis; and to determine if there

solution. This study is not yet published.23

is a difference between IO specimen results when
the first 2 mL of IO blood were discarded and not

Technical Considerations

discarded. An i-STAT Handheld point of care (POC)

Most of the reported study data was based on IO

analyzer (Abbott Laboratories) was used to evaluate

laboratory specimens obtained prior to any

for sodium, potassium, chloride, TCO2, anion gap,

infusions or flush, therefore results may differ fromionized calcium, glucose, urea nitrogen (BUN),

samples obtained post-infusions.

creatinine, hematocrit, and hemoglobin. All blood
samples were drawn and placed into green top

It is important to check with your laboratory forlaboratory tubes containing sodium heparin andspecimen processing capabilities. Blood samples

later the blood was placed into the sample cartridges

for laboratory analysis can be drawn from thefor analysis. Once initial access was obtained, a

EZ-IO® Catheter by connecting a syringe directly tobaseline sample was obtained at approximately thethe EZ-IO® Catheter hub. (Note: the only times asame time from all access points. For a comparison

syringe should be connected directly to an EZ-IO®

of IO samples pre- and post- 2 mL discard, the initial

Catheter hub is for drawing laboratory samples,

2 mL IO sample was aspirated; then a subsequent 2

for administration of medications that require verymL sample was collected. For the post-infusion wait

small fluid volumes for precise doses to infants andstudy, a five minute infusion of normal saline wassmall children, or for catheter removal).

started to the IO sites and then stopped. The initial

For most laboratory studies, the first 2 mL should

post-infusion wait period was five minutes. Timebe aspirated and discarded prior to withdrawal ofintervals were reduced and results compared tolaboratory samples. If necessary (e.g. pediatrics),

baseline were similar with as little as one minutethe first 2 mL may be saved for certain tests, such

wait time. A target wait time of two minutes was

as blood typing or blood cultures.9,EO Aspiration of
EO = Expert Opinion

80

81

LABORATORY ANALYSIS/BLOOD SAMPLING

adequate volumes for laboratory samples may vary

includes a brief review of the literature, discusses

greatly between patients; and IO blood samples clot

the limitations associated with studies on IO derived

more rapidly than venous samples. Therefore, samples

blood samples, and recommends IO blood may

should be prioritized in order of importance.

only be useful in cases of suspected overdose fortoxicology.26 A 2015 article discusses use of bone

Consider drawing initial blood samples into smaller

marrow aspiration fluid using automated blood

volume syringes, and placing them immediately

cell counters and the potential advantages andinto sample tubes. Point of care (POC) analyzers

limitations of this practice. Amongst the key points

may more easily process IO samples (for available

are bone marrow fluid can be used as a substituteparameters) as they require less volume. Samples

for venous blood in emergency situations, at least

must be identified as IO blood so laboratory personnel

for the measurement of red cell parameters; andcan determine the suitability of equipment for IO

the complexities of the comparison between the

blood lab processing; and accurately interpretcomposition of blood aspirated from bone as “boneresults based on the possible presence of stem cells

marrow fluid” compared to peripheral blood, for

not found in peripheral blood; or cell counts that are

which most instruments were designed, create

known to differ between IO derived blood samples

difficulties when assessing for hematology.27

and those from arterial or venous sources.
1

Tallman CI, Darracq M, Young M. Analysis of intraosseous
blood samples using an EPOC point of care analyzer during

Questions about the use of results from intraosseous

resuscitation. Am J Emerg Med 2016; epub ahead of print

access-derived blood samples were raised in 2008

http://dx.doi.org/10.1016/j.ajem.2016.12.005.

in two editorial letters; and again in a 2014 letter by

2 Veldhoen ES, de Vooght KMK, Slieker MG, Versluys AB, Turner

Cervinski. Nicoll mentioned possible incompatibilities

NMB. Analysis of blood gas, electrolytes and glucose fromintraossseous samples using an i-STAT point-of-care analyser.

between the available laboratory analyzers with

Resuscitation 2014;85:359-363. http://dx.doi.org/10.1016/j.

IO blood that could result in blockage.24 The
recommendation was that laboratory tests only

resuscitation.2013.12.002.
3

correlates with venous blood in healthy subjects using point-of-

be carried out on either arterial or femoral venous

care analyzers. Ann Med Emerg 2013;62(4s):S40.TS

samples during resuscitation. In a letter supportinguse of IO derived blood samples, Dr. Salter respondedwith research supporting several laboratory
parameters and stated IO samples were a “legitimate”

4arterial access; and stated that IO samples should
be appropriately labeled.25 Cervinski’s 2014 letter

Philbeck T, Miller L, Montez, Powell T. IO blood for enzymes
and blood gas analysis. Unpublished manuscript. 2010.TS

5

Miller LJ, Philbeck TE, Montez DF, Spadaccini CJ A new studyof intraosseous blood for laboratory analysis. Arch Pathol Lab

technique that could guide care especially inconsideration of the time delay in gaining venous orMontez DF, Puga TA, Garcia MR et al. Intraosseous blood

Med 2010;134(9):1253-60.TS
6

Hurren JS. Can blood taken from intraosseous cannulations beused for blood analysis? Burns 2000;26(8):727-30.

LABORATORY ANALYSIS/BLOOD SAMPLING

7

8

Ummenhofer W, Frei FJ, Urwyler A, et al. Are laboratory values

Larsson T. Analysis of intraosseous samples using point of carepatients? Resuscitation 1994;27(2):123-8.

technology – an experimental study in the anaesthetized pig.

Grisham J, Hastings C. Bone marrow aspirates an accessible
and reliable source for critical laboratory studies. Ann Emerg
Med 1991;20(10):1121-24.

9

18 Strandberg G, Eriksson M, Gustafsson MG, Lipcsey M,

in bone marrow predictable for venous blood in paediatric

Brickman KR, Krupp K, Rega P, Alexander J, Guinness M.
Typing and screening of blood from intraosseous access. Ann
Emerg Med 1992;21(4):414-7.

10 Unger H, Spivey WH, McNamara RM, et al. Comparison of
intraosseous and intravenous CBC and Astra 8 in swine.
Ann Emerg Med 1986;15:647.
11 Orlowski JP, Proemka DT, Gallagher JM, et al. The bonemarrow as a source for laboratory studies. Ann Emerg Med
1989;18(12):1348-51.
12 Kissoon N, Rosenberg H, Gloor J et al. Comparison of the

Resuscitation 2012;83(11);1381-5. doi:10.1016/ j.resuscitation.
2012.04.007.
19 Larsson T, Strandberg G, Eriksson M, Bondesson U, Lipcsey M,
Larsson A. Intraosseous samples can be used for opioidmeasurements – An experimental study in the anaesthetized
pig. Scand J Clin Lab Invest 2013;73(2):102-6. doi:10.3109/
00365513.2012.744088. Epub 2012 Nov 22.
20 Eriksson M, Strandberg G, Lipcsey M, Larsson A. Troponin I
can be determined in intraosseous aspirates in a porcine shockmodel. Clin Lab 2015. doi:10.7754/Clin.Lab.2015.141212.
21 Eriksson M, Strandberg G, Lipcsey M, Larsson A. Evaluationof intraosseous sampling for measurements of alanine
aminotransferase, alkaline phosphatase, aspartate
aminotransferase, creatinine kinase, gamma-glutamylacid-base status of blood obtained from intraosseous andtransferase and lactate dehydrogenase. Scand J Clin Lab Invest

central venous sites during steady-and low-flow states.

2016; epub ahead of print 29 Sep 2016. doi:10.1080/00365513.

Crit Care Med 1993;21(11):1765-9.

2016.1230774.

13 Kissoon N, Peterson R, Murphy S, Gayle M, CeithamL E,

22 Strandberg G, Lipcsey M, Eriksson M, Lubenow N, Larsson A.

Harwood-Nuss A. Comparison of pH and carbon dioxide

Analysis of thromboelastography, PT, APTT and fibrinogen intension values of central venous and intraosseous blood

intraosseous and venous samples–an experimental study.

during changes in cardiac output. Crit Care Med 1994;22(6):Scand J Trauma Resusc Emerg Med 2016;24:131 doi:10.1186/

1010-5.

s13049-016-0318-0.

14 Kissoon N, Idris A, WenzelV, Murphy S, Rush W. Intraosseousand central venous blood acid-base relationship during
cardiopulmonary resuscitation. Pediatr Emerg Care 1997;13(4):250-3.
15 Abdelmoneim T, Kissoon N, Johnson L, Fiallos M, Murphy S.
Acid-base status of blood from intraosseous and mixed venous
sites during prolonged cardiopulmonary resuscitation and drug
infusion. Crit Care Med 1999;27(9):1923-8.
16 Johnson L, Kissoon N, Fiallos M, Abdelmoneim T, Murphy S.
Use of intraosseous blood to assess blood chemistries andhemoglobin during cardiopulmonary resuscitation with drug
infusions. Crit Care Med 1999;27(6):1147-52.
17 Strandberg G, Larsson A, Lipcsey M, Eriksson M. Intraosseous
blood aspirates analysed by a portable cartridge-based device.
Critical Care 2011;15(S1):P138. doi:10.1186/cc9558.

23 Teleflex internal unpublished preclinical study data November
30, 2016.
24 Nicoll SJ, Rochester SJ. Blood sampling through intraosseous
needles: time to stop? Resuscitation 2008;79:168 [discussion
168-9].
25 Salter R, Maconochie I. Reply to Letter: Blood samplingthrough intraosseous needles: time to stop? Resuscitation
2008;79:168.
26 Cervinski MA. Laboratory analysis of intraosseous blood: bad tothe bone? Clin Chem Lab Med 2014. doi:10.1515/cclm-20140104.
27 d’Onofrio G, Zini G. Analysis of Bone Marrow Aspiration Fluid
Using Automated Blood Cell Counters. Clin Lab Med 2015;35(1): 25-42. http://dx.doi.org/10.1016/j.cll.2014.10.001.

82

83

INDUCED HYPOTHERMIA BY INTRAOSSEOUS ACCESS

Induced Hypothermia
by Intraosseous Access

A 2011 swine study compared the efficacy of chilledsaline administration between the IO and IV routes.6
Endpoints were brain, esophageal, and rectal
temperatures digitally recorded after a 45-minute

The 2010 Guidelines from the American Heartinfusion of chilled normal saline. The results

Association include recommendations for therapeuticsuggested no clinical or statistical difference between

hypothermia. One method of inducing therapeutic

IV and IO routes for infusion of chilled saline for

hypothermia (TH) includes vascular administration

therapeutic hypothermia and the ability of the twoof chilled fluids.

routes to facilitate reduction of core temperature.

A 2007 article described successful use of the EZ-IO®

Another 2011 swine study concluded the peripheral

Device for induction of therapeutic hypothermia

IV route was superior to IO for induction ofat an urban EMS service. For the observed period,

therapeutic hypothermia.7 The total infusion volume

paramedics administered chilled saline for post-of chilled saline in the IV group was approximately

resuscitation induction of hypothermia in 68

2.5 times that of the IO route and there was apatients. The IO route was used alone or with asignificantly slower infusion rate for the IO route

peripheral IV line in 74% of the TH cases.

in this study.

1

2

Truhlar et al. described use of the EZ-IO Device®

1

to induce therapeutic hypothermia (post-

American Heart Association 2010 American Heart Association
guidelines for CPR and ECC. Part 9-Post-Cardiac Arrest Care.

resuscitation) in a two year-old pediatric patient.
The patient survived and was ultimately discharged

Circulation 2010;122(3 suppl.):S769-78.
2

3

been no clinical studies evaluating the effects ofResuscitation 2010;81(2):262-3.
4

Ornato JP, Peberdy MA, Kurz MC. Abstract P134: A building
block strategy for optimizing outcomes from out of hospitalchilled fluids on the bone marrow.

4

cardiac arrest. Circulation 2009;120:S1470-a.
5

Mader TJ, Walterscheid JK, Kellog AR, Lodding CC. The
feasibility of inducing mild therapeutic hypothermia after cardiac

Preclinical Studies

resuscitation using iced saline infusion via an intraosseous

In a 2007 published study in swine, investigatorsconcluded that mild therapeutic hypothermia can be

Truhlar A, Skulec R, Rozsival P, Cerny V. Efficient prehospitalinduction of therapeutic hypothermia via intraosseous infusion.

Though there have been case reports on therapeutic
hypothermia induction via the IO route, there have

Myers BJ, Lewis R. Induced cooling by EMS (ICE): year one inRaleigh/Wake County. JEMS 2007;32:S13-5.

home without neurological consequences.

3

needle. Resuscitation 2010;81:82-6.TS
6

Miller L, Montez DF, Philbeck TE, Puga TA, Morgan J. Infusing

effectively induced after successful resuscitation ofchilled saline via the intraosseous route is equivalent to infusion

prolonged ventricular fibrillation through infusion of

via the intravenous route in reducing the core temperature inchilled saline via the IO catheter.5

swine. Prehosp Emerg Care 2012;16(1):152.doi:10.3109/10903127.
2011.624676.TS

SPECIAL CONSIDERATIONS

7

Larabee TM, Campbell JA, Severyn FA, Little CM. Intraosseous
infusion of ice cold saline is less efficacious than intravenous
infusion for induction of mild therapeutic hypothermia in a

Note: Use of the EZ-Stabilizer® dressing is strongly
recommended for additional stabilization as theswine model of cardiac arrest. Resuscitation 2011;82:603-6.

weaker bone structure may increase chance of

doi:10.1016/j.resuscitation.2011.01.007.

needle set dislocation. Reevaluation is especially

Special Considerations

important in this patient population also.
* Osteoporosis is a contraindication for the sternal insertion site®

®

with the EZ-IO T.A.L.O.N.™ and EZ-IO Sternal device.

Can the EZ-IO® Catheter Remain in Place
during a CT Scan?
There are no known reports of problems associatedwith inserted IO catheters during computed
tomography (CT). If an IO catheter is placed in
the proximal humerus, the affected arm should besecured in the adducted position (with the arm at
the patient’s side). An IO catheter may cause slightscatter artifact on the images obtained.

Can the EZ-IO® Catheter Remain in Place
during an MRI Scan?
No. The EZ-IO® Needle Set is made of 304 stainlesssteel, and should not be present during MRI
procedures. The metal in the EZ-IO® Catheter could
potentially be problematic if subjected to highmagnetic forces.

Can the EZ-IO® Needle Sets Be Used in
Patients with Osteoporosis?
Yes. The combination of the needle set design androtation of the EZ-IO® Device achieves intraosseousaccess with little disruption of bone architectureduring the insertion process. The EZ-IO® Device
results in a precise hole in the bone, requires
minimal force for insertion, and provides greater
control than a needle set manually rotated into bone.1
See Figure 28a.

Should an IO Device Be Inserted in
the Humerus on the Same Side asa Mastectomy?
It is recommended that proximal humerus IO
insertion be avoided on the affected (postmastectomy) side if possible, but it is not an
absolute contraindication.EO

Is IO Access Contraindicated in a Patientwith Avascular Necrosis?
By definition, a patient with avascular necrosis lacks
adequate vasculature at the affected site. While notcontraindicated, IO access should be avoided at
the avascular site, and an alternative insertion siteshould be selected.EO

Is IO Access Contraindicated in
Osteogenesis Imperfecta?
While osteogenesis imperfecta is not an absolutecontraindication for IO use, the degree ofosteogenesis imperfecta may present challenges to
IO vascular access. The soft bones of an osteogenesis
imperfecta patient may prevent the IO catheter frommaintaining an adequate seal for infusion. It may also
be difficult or impossible to adequately stabilize an
IO catheter in a patient with osteogenesis imperfecta.
There is one known case regarding IO vascular
EO = Expert Opinion

84

85

RESEARCH

access in an osteogenesis imperfecta patient. A

2imperfecta (IO in OI). Resuscitation 2009;80(12);1442-3.

2009 article describes the case of an adult male incardiac arrest requiring emergency vascular access.
Several IO attempts resulted in the IO catheters

Nutbeam T, Fergusson A. Intraosseous access in osteogenesis
doi:10.1016/j.resuscitation.2009.08.016.

3

Frascone R, Kaye K, Dries D, Solem L. Successful placement ofan adult sternal intraosseous line through burned skin. J Burn

immediately becoming loose, and the inability

Care Rehabil 2003; 24: 306-8.

to secure or flush the IO devices. It was later
determined that the patient suffered from Type III
osteogenesis imperfecta, a more severe form of
the disease.2

Can an IO Device be Used In Burn Patients?
Yes. An IO device can be inserted through burned
skin as long as the underlying bone has not been
compromised.3 It is important to be aware thatswelling due to post-burn edema may be severe
enough to affect the stability of the IO access site
so frequent reevaluation for signs of dislodgement
is important.

Can the EZ-IO® Device Be Used In
Hyperbaric Medicine?
The driver’s performance and electrical compatibility
within the hyperbaric chamber has not been tested
and there is no data to support its use in that clinicalsetting. Under normal circumstances, vascularaccess is obtained prior to entry into the hyperbaric
chamber; however, if the need to obtain IO vascularaccess arises in the chamber, a manual insertion isrecommended due to the risk of spark in an oxygenrich environment. There is no contraindication to IO
infusion in the hyperbaric chamber.
1Miller L, Philbeck T, Bolleter S, Garcia G. Tactile feedback
comparison of three types of intraosseous access devices forneedle insertion accuracy. Ann Emerg Med 2010;56(3):S133.
Research sponsored by Teleflex Incorporated.

RESEARCH
Has Research Been Conducted
Demonstrating the Safety and Efficacy of
IO Vascular Access?
The body of research regarding intraosseous
vascular access is extensive. The safety and efficacy
of IO access has been studied in a variety of clinicalenvironments worldwide. Clinical literature includes
over 500 articles describing IO access (referred toas “bone marrow” access in early literature fromthe 1920s). Teleflex has compiled an extensive IO
bibliography of published articles and studies.
This bibliography is available online at:
http://www.teleflex.com/en/usa/ezioeducation/
documents/General_IO_Bibliography.pdf
Facts related to intraosseous vascular access inpublished literature (as of May 2017):•

Over 500 articles describing intraosseous
vascular access•Greater than 285 articles (in six languages)
regarding use of the EZ-IO® Device– Approximately 85 articles describing casestudies or clinical trials– Over 5,400 patients included in researchstudies

RESEARCH

How Does the EZ-IO® Device Comparewith Other IO Products?

A 2010 study with a power-driven IO needle set

All IO vascular access products are designed toconfirmed high reliability in discerning accuratedeliver fluids and medications through the IO space.

needle set placement by tactile feedback (in models

Devices fall into three basic categories: manual,designed to mimic bone density differences).6

impact-driven /spring-loaded, and semi-automatic
devices. The EZ-IO® Device is the only battery-outer bone cortex to softer cancellous bone is felt.

1

in intraosseous infusion-a systematic review. Resuscitation

powered device on the market. Several researchstudies and review articles have examined

2012;83(1):20-6. doi:10.1016/j.resuscitation.2011.07.020.
2

Paxton JH. Intraosseous vascular access: A review. Trauma
2012;14(3):195-232. doi:10.1177/1460408611430175.

comparative clinical data among various IO deviceson the market.1-4

Weiser G, Hoffmann Y, Galbraith R, Shavit I. Current advances

3

Petitpas F, Guenezan J, Vendeuvre T, Scepi M, Oriot D,
Mimoz O. Use of intraosseous access in adults: a systematic
review. Crit Care 2016;20:102. doi:10.1186/s13054-016-1277-6.

The specially designed cutting EZ-IO® Needle Set

4

and powered driver enables clinicians to have better

Adult Intraosseous Catheter Complication and Review of the
Literature. Crit Care Med 2016. doi:10.1097/CCM.

control of insertion with tactile feedback when

0000000000001714 [April 7th. Epub ahead of print].

compared with manual or spring-loaded /impact
devices.5-6 The photographs in Figures 28a and 28b
demonstrate the symmetrical cutting tip of the
EZ-IO® Needle Set (Figure 28a) provides a more

Greenstein YY, Koenig SJ, Mayo PH, Narasimhan M. A Serious

5

Teleflex internal study done in cadaveric bone.

6

Miller L, Philbeck T, Bolleter S, Garcia G. Tactile feedback
comparison of three types of intraosseous access devices forneedle insertion accuracy. Ann Emerg Med 2010; 56(3):S133.TS

precise entry hole into the medullary space which
may minimize the risk of extravasation when

Figure 28acompared to the hole created by a spring-loaded
impact driven IO device (Figure 28b). Figures 28aand 28b show a microscopic view of bones following
IO insertion. There was no extravasation of the blue
dye injected after placement of the EZ-IO® Catheter,
and no microscopic fractures, as seen with use of

Image of bone, post-EZ-IO® Catheter insertion

the spring-loaded impact device.5

Figure 28b

The EZ-IO® Device helps prevent over-penetrationof the bone by allowing the clinician to immediately
stop the procedure by releasing the driver trigger
when the sensation of the change from the hard
Image of bone post IO access using impact-driven device

86

87

TELEFLEX CUSTOMER SERVICETELEFLEXCUSTOMER SERVICE
Is there someone available at Teleflex toprovide assistance?

Is there more information available on the
EZ-IO® Device (e.g. training, specifications)?

Yes. Our support staff includes physicians, nurses,

Teleflex provides multiple resources:

paramedics, educators, and engineers. All calls••

made in the U.S. are toll-free. You may also go

On-site training with expert clinical staff
Clinical and Medical Affairs, including a dedicatedto teleflex.com/ezioeducation for more region

research team, Global Research, and Scientificspecific information.

Services. Questions may be directed to:Clinical.Affairs@teleflex.com

Clinical Questions: 24 hours a day, 7 days a week••

Clinical support in U.S.: 800.680.4911
Clinical support outside U.S.: +1.800.680.4911

•
•
•
•

•
•

Customer service in U.S.: 866.479.8500

Training videos
Online training documents
Frequently asked questions/Discussion Topics
on IO

Technical Questions: Monday-Friday 8:00am to
5:30pm CST/CDT (GMT-6/GMT-5)

Ready-to-use training presentations••

24/7 clinical support
Teleflex web site (www.teleflex.com)

Customer service outside U.S.: +1.866.479.8500
If additional assistance, or answers to specific

Where should EZ-IO® Device problems(or complications) be reported?

•

Complications should be reported to Teleflex
at the earliest possible time. Please use the•••Customer Service number: 866.479.8500 or
24-hour emergency number: 800.680.4911
Teleflex can also answer questions and provide
guidance regarding U.S. FDA reporting andcompliancequestions are needed, please call Customer Service(toll-free in U.S.): 866.479.8500 (Outside U.S.:+1.866.479.8500).

Teleflex is a global provider of medical technologies designed to improve the health and quality of people’s
lives. We apply purpose driven innovation – a relentless pursuit of identifying unmet clinical needs – tobenefit patients and healthcare providers. Our portfolio is diverse, with solutions in the fields of vascularand interventional access, surgical, anesthesia, cardiac care, urology, emergency medicine, and respiratorycare. Teleflex employees worldwide are united in the understanding that what we do every day makes adifference. For more information, please visit teleflex.com.
Teleflex is the home of Arrow®, Deknatel®, Hudson RCI®, LMA®, Pilling®, Rüsch® and Weck® – trusted brands
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Phone +1 610 225 6800, 550 E. Swedesford Road, Suite 400, Wayne, PA 19087, USA

Regional Offices
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For more information, please visit teleflex.com.

Teleflex, the Teleflex logo, Arrow, Deknatel, EZ-IO, EZ-Connect, EZ-Stabilizer, EZ-IO T.A.L.O.N., Hudson RCI, LMA, Pilling, Rüsch,and Weck are trademarks or registered trademarks of Teleflex Incorporated or its affiliates, in the U.S. and/or other countries. All othertrademarks are trademarks of their respective owners.
Information in this document is not a substitute for the product Instructions for Use. The products in this document may not be available
in all countries. Please contact your local representative. All data current at time of printing (11/2017).
© 2017 Teleflex Incorporated. All rights reserved. MC-003266 Rev 0.1