Ez-io Manual

[Patrice Mieczkowski]

TheEZ-IO Intraosseous Infusion System is the leading choice for intraosseous access across multiple health care settings, and is used by 90 percent of US advanced life support ambulances, over half of US Emergency Departments, and the US Military.

The EZ-IO Manual Needle Set allows medical personnel to immediately secure vascular access manually without removing body armor and exposing the operator to additional risk of injury. Six (6) FDA-cleared peripheral sites provide multiple options for the medic, helping to ensure rapid care for patients.

The EZ-IO T.A.L.O.N. Needle Set allows manual I/O insertion at all 7 extremity sites, including the sternum (sternum, bilateral proximal humerus, bilateral proximal tibia, and bilateral distal tibia). It is part of the MARCH system and provides fast and accurate IO access. Sold as a set of 6.

Intraosseous (IO) vascular access use in children began in the 1940s, but the practice was abandoned when intravenous catheters were invented. A resurgence of interest in IO access began decades later, and the procedure was first added to the Pediatric Advanced Life Support guidelines in 1986. Intraosseous access has now become the preferred access method over central line placement and for peripheral IV access that takes longer than 30 seconds.

Initially, manual intraosseous needles were used for neonatal resuscitations because they were the only tools available. Once we learned the skill, manual IO needles served their purpose well. Cup the needle top in your palm and insert the needle with a rotational pressure perpendicular into the bone until you feel a trapdoor effect as the needle passes through the cortex into the medullary space. Later, when the EZ-IO drill was invented for IO needle insertions, we immediately fell in love and our affections for the manual IO needles waned. Now, however, evidence suggests that our first love, the manual needles, deserves to be reconsidered for attaining intravenous access in neonates.

Umbilical venous access is often recommended for emergency venous access in newborn resuscitations. That procedure, however, is rarely performed for newborns, and maintaining the equipment and skills are challenging. In fact, it is reportedly done in only 0.12 percent of all births. (Arch Pediatr Adolesc Med. 1995;149[1]:20.)

Consequently, emergency physicians are significantly less experienced with this technique. Umbilical venous catheterization is an important skill, but studies show that it is significantly faster to establish intraosseous access than an umbilical venous catheter. (Pediatrics. 2011;128[4]:e954; Pediatr Crit Care Med. 2018;19[5]:468.) My ED doesn't place many intraosseous needles because our nurses are skilled at placing intravenous catheters in even the smallest neonates. Nevertheless, the smallest neonates presenting in cardiac arrest are the ones who may require IO needle placement for intravenous access.

Evidence suggests that manual and EZ-IO access are associated with a significant number of failures in neonates because of small bone size and the difficulty in judging the depth and when the needle passes into the medullary space. The trapdoor sensation as the needle drops through the cortex is much easier to detect with manual IO needles than drill-inserted ones. The shortest EZ-IO needle used for neonates is vulnerable to adipose tissue back pressure in chubby neonates even when you maintain the 5-mm-of-needle-above-the-skin rule. I have seen perfectly placed needles dislodged moments later by the mechanics of adipose pushing back on the needle hub.

There is other hard evidence that our success rates with intraosseous needle placement in infants is nowhere near that pristine. Several smaller, post-mortem studies suggest our failure rate for neonates is much higher. A review based on postmortem CT scans found that tibial IO needle insertion had a 53 percent failure rate (31 cases with 42 devices) in infants 6 months and younger. (Prehosp Emerg Care. 2020;24[5]:665.) A study using pediatric cadavers reported that 16 of the 34 ION devices (47%) were malpositioned. (Resuscitation. 2019;145:1.)

We learned recently that one brand of manual IO needles commonly used for neonates had been recalled, but we learned that the needles sold with the EZ-IO drill are also approved for manual application. Problem solved!

4 Berenson JR, Yellin O, Blumenstein B, et al. Using a powered bone marrow biopsy system results in shorter procedures, causes less residual pain to adult patients, and yields larger specimens. Diagnostic Pathology 2011;6:23. Research sponsored by Teleflex Incorporated.

5 Miller LJ, Philbeck TE, Montez DF, et al. Powered bone marrow biopsy procedures produce larger core specimens, with less pain, in less time than with standard manual devices. Hematology Reports 2011;3:e8.t. Research sponsored by Teleflex Incorporated.

7 Garcia G, Miller LJ, Philbeck, T, Bolleter S, Montez, D. Tactile feedback allows accurate insertion of a powered bone access device for vertebroplasty and bone marrow sampling procedures. J Vasc and Interv Radiol 2011;22(3):S86. Research sponsored by Teleflex Incorporated.

Refer to the Instructions for Use for a complete listing of the indications, contraindications, warnings and precautions. Information in this material is not a substitute for the product Instructions for Use.

Refer to the Instructions for Use for a complete listing of the indications, contraindications, warnings, and precautions. Information in this document is not a substitute for the product Instructions for Use. Not all products may be available in all countries. Please contact your local representative.

When IO access is the best option for vascular access, clinicians and emergency care providers can trust the BD Intraosseous Vascular Access System to deliver fluids and/or medications safely during resuscitations and life-saving procedures.

With innovations designed to deliver safety, reliability and performance, the BD Intraosseous Vascular Access System offers enhanced control and a safety feature designed to protect against needlestick injuries.

If you prefer to achieve IO access manually, we also offer the BD Intraosseous Manual Driver, which uses pressure from the user to push a needle into the IO space. A single-use disposable hypodermic needle is connected to a needle hub, and a stylet is connected to the manual driver.

BD Intraosseous Needles are the only IO needles that feature an integrated passive needle tip safety designed to protect against needlestick injuries. So, the BD Intraosseous Vascular Access System can protect healthcare workers from inadvertent needlesticks, that are especially common in emergent settings:

Unsuccessful insertions increase delays in treatment, reduce patient satisfaction and significantly increase risk of complications.7 Over 33% of adults and up to 50% of children who present to a hospital and require a PIVC are reported to have difficult venous access (DVA), making first-attempt success harder to achieve.8

ACEP Policy Statement

There are situations in the emergency department when intravenous access procedures fail or are insufficient to meet the clinical needs of the patient. Alternative access methods must be available under such circumstances and their usage should be a part of the emergency medicine practice privileges. These alternate access modalities include, but are not limited to, intraosseous lines.10

INS Infusion Therapy Standards of Practice 2021

IO access has a reported high rate of first-time insertion success with low complications. Insertion of an IO device may avoid delays to delivery of necessary medication and fluid. [...] Anticipate use of the IO route in the event of adult or pediatric cardiac arrest if IV access is not available or cannot be obtained quickly. Pediatric advanced life support guidelines recommend the use of the IO route as the initial vascular access route in case of cardiac arrest.13

NAEMSP Position Statement for Out-of-Hospital Settings

IO access may be appropriate for primary vascular access in select cases.14 In out-of-hospital environments, IO access may provide significant time savings that could benefit patients in emergent situations by decreasing the time required to achieve access and the time required to administer the necessary fluids and medications.15

Our Medical Information (MI) team of scientists and nurses is available via phone at 1-800-555-7422 and email to answer any technical or clinical questions you might have about BD products, and the procedures in which they are used.

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Background: In 2007, an update was released to the pediatric and neonatal septic shock guidelines, which emphasized early use of therapies, specifically, first-hour fluid resuscitation and inotrope therapy. This has led to increased use of intraosseous (IO) access as a source of vascular access. Previously, IO access could be obtained only via a manual IO placement. New semi-automatic devices, such as EZ-IO() (Vidacare, Shavano Park, TX), allow for safer and quicker IO access. Data support the use of semi-automatic devices during the acute resuscitation period.

Case report: The patient was a 7-month old girl with VACTERL association (Vertebral defects, Anal atresia, Cardiac defects, Tracheo-Esophageal fistula, Renal anomalies, Limb abnormalities) and complex past medical history. The patient experienced a "choking episode," which led to subsequent apnea and cyanosis. The patient presented in shock to a local pediatric emergency department. After multiple unsuccessful intravenous line attempts, IO access was obtained using the EZ-IO(). Once in the pediatric intensive care unit with venous access, the IO device was removed and the site had "red bulls-eye target shape" damage to the skin, which appeared consistent with the EZ-IO() flange. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: IO device use is increasing due to the most recent pediatric and neonatal septic shock guidelines, which emphasize first-hour fluid resuscitation and inotrope therapy. It is vital that emergency physicians be aware of the adverse effects of semi-automatic IO devices, including dermal abrasion, which has not been reported previously. With proper training and familiarity, it is possible to avoid dermal abrasion as an adverse effect of the semi-automatic IO device.

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