Why Sternal IO?
Sternal IO for Vascular Access
Traditionally, intravenous (IV) access has been used for rapid fluid and medication administration during resuscitation. IV access times and the ability to start an IV vary greatly among users and the situational environment. Starting an IV on a patient with hypovolemic shock or cardiac arrest presents a real challenge. Alternatives to IV access such as central venous catheterization or a venous cut-down are very time consuming and challenging in the best of situations. Most pre-hospital medical personnel are not equipped or trained to perform these procedures. Intraosseous (IO) Infusion systems enable the user to rapidly, safely and effectively administer emergency fluids and medications into the vascular system through the bone marrow of the manubrium.
The primary indication for use for IO Infusion is the need for rapid or emergency vascular access when conventional/intravenous access has failed.
Many organizations define this as two failed IV attempts. IO Infusion is an accepted standard of care and treatment modality. It is endorsed by the American Heart Association, Advanced Trauma Life Support, Advanced Cardiac Life Support courses as well as the European Resuscitation Council. IO Infusion is also taught as part of military medicine training and Tactical Combat Casualty Care guidelines. Success rates for IO infusion are as high as or higher than IV.
Think of the bone marrow as the “non-collapsible vein”.
Any fluids or medications that can be administered via IV can also be administered via IO Infusion. Flow rates and volume that can be delivered by IO Infusion are comparable to IV and the time for fluids or medications to reach the vasculature, concentrations in the blood, and effects on target organs are similar between IO Infusion and IV. Pyng Medical’s FAST1™ IO Infusion device is safe to use in patients 12 years of age and older. Procedures to administer IO infusion are relatively simple and can be taught quickly to all medical providers in military, pre-hospital, or hospital environments. FAST1 can be used safely and effectively during CPR, so that CPR guidelines can be followed, and also can be used when a cervical spine collar is in place.
The main indication for use is the need for rapid or emergent vascular access when conventional / intravenous access has failed. Most organizations define this as two failed IV attempts. (1) The rate of IV failure varies significantly based on the skill level of the provider, the location in the pre-hospital or hospital environment, associated injuries and the blood pressure of the patient. Studies have shown a 60% to 95% IV infusion success rate. Another study focused just on emergency IV access demonstrated a 10% failure rate. The average time it takes to initiate an IV infusion also varies significantly from 1.5 minutes to 13 minutes. (2,4,6,7,11) Central venous catheterization (CVC) is a commonly taught, physician level skill that is often used if IV access cannot be obtained. This is a challenging procedure under the best of conditions. IO infusion can be used in an emergent situation as a “bridge” to a CVC; allowing rapid vascular access until a CVC can be performed under better conditions. First attempt for a CVC is 60% with a mean time of 9.9 minutes in one study. CVC’s also have higher rates of infection noted at 5.3 per 1,000 catheter days as compared to IO infusion. (6) A venous cut-down is another alternate procedure if IV access cannot be obtained. This is taught in ATLS and some military medical training. The mean infusion time for the cut-down group was 6.6 +/- 4.3 minutes. (10,13)
FAST1 can be inserted and used during CPR and does not interfere with other resuscitation requirements. This device can also be used with a cervical spine collar in place for immobilization. (2) The device can be inserted through deep skin burns. (3) The success rates for IO infusion are as high as or higher than for traditional IV infusion. McNabb states “The success rate of vascular access for sternal IO users with training but no previous clinical experience with the IO system was 74%; for those with at least one previous IO device use, 95%…” Median access time for all users was 60 seconds while mean access time was 77 seconds (4) Another study notes first time IO access and infusion success from 80% – 100%, “typically” in 1 minute or less and the majority of IO insertions completed within 2 minutes in all studies. (8) The flow rate or infusion rate of an IO infusion are comparable to the traditional IV infusion. (8) Flow rates will vary based on a number of factors. The two most important variables are the blood pressure of the patient and the type of infusion system used. Up to 80 ml/minute was achieved using the tradition gravity feed drip system, and greater than 150ml/minute using a syringe bolus technique. (4,11,15) Any fluids or medications that can be administered by the IV route can be administered IO. (9) Commonly used medications and fluids used in resuscitation that have been used with IO infusion include but are not limited to lidocaine, epinephrine, doapamine, vasopressin, blood, plasma hypertonic saline, 0.9% normal saline, Lactated Ringer’s, morphine, valium, succinylcholine, heparin, antitoxins and methylpredisolone. (8) The pharmacokinetics of IO infusion are similar to IV regarding time to enter the vasculature, concentrations in the blood and effects on target organs. (10)(9) With regard to clinically effective doses to target organs, IO infusion is equivalent to or quicker than IV. Note that in cases of severe shock, changes in peripheral venous flow rates make venous access very difficult and may potentially delay the time for medications to reach the target organs by IV. (5) The paper by Halvorsen states “….a number of studies have indicated essentially identical plasma concentrations or onset of physiologic effects of drugs and fluids when IO infusions were compared to both central or peripheral intravenous infusions…”(7) The sternal IO procedure is relatively simple and can be utilized by multiple levels and types of medical providers in the pre-hospital and hospital environments. It has been used by EMT- Basics to EMT paramedics, military medics, nurses, physician’s assistants and physicians. In the pre-hospital environment it provides a safe and quick alternative to the traditional IV. (7,8) A 93.1% “overall correct use” rate was documented after only a 1 hour lecture followed by 1 hour hand-on practice in a study using EMT-Basic students as the sample group. (12)
FAST1 is compatible with all current recommendations and procedures for conducting CPR chest compressions.
FAST1 is placed in the manubrium of the sternum. The manubrium is located at the cephalad (top) portion of the sternum. The hand placement for CPR chest compressions is located just cephalad of the xiphoid process (bottom portion) of the sternum. The position and placement of FAST devices and the hands for chest compressions are separated by the entire body of the sternum. Deployment of FAST1 Sternal IO can be accomplished while chest compressions are temporarily halted, which takes only a few seconds. Chest compressions (if done correctly) will not affect the placement of the FAST infusion tube. With proper deployment of FAST1 , chest compressions can continue while fluids are administered.