Running Head: IO ACCESS IN SEPTIC PATIENTS

Intraosseous Access in Septic Patients

Danielle Fleming, BSN, RN, SCRN
The University of Texas at Tyler College of Nursing

In partial fulfillment of the requirements of

Capstone I NURS5201.060
Linda Rath, PhD, RN
March 20, 2017
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Intraosseous Access in Septic Patients

Introduction

In patients who present to the Emergency Department (ED) in septic shock

without pre-existing access, treatment may be delayed by attempts at peripheral intravenous (IV)

access or the insertion of a central venous catheter (CVC). Delaying fluid resuscitation and

administration of antibiotics can adversely affect morbidity and mortality. Patients with severe

sepsis have hospital mortality rates between 18-50% with the average in the United States being

28% (Surviving Sepsis Campaign, 2012). According to the Surviving Sepsis Campaign Bundle,

within the first three hours of presentation of septic shock or severe sepsis the following are to be

completed: blood cultures prior to antibiotic administration, lactate level, administration of broad

spectrum antibiotics, and administration of 30 ml/kg crystalloid (Surviving Sepsis Campaign,

2012). Intraosseous (IO) access is a quick and effective way to establish a means for blood

sampling, antibiotic and fluid administration without delaying treatment for IV or CVC access.

Major complications with IO insertions and use are extremely rare with low minor complication

rates. IO access is accepted standard practice in pediatric patients, however is underutilized in the

adult population.

The success of IO access in other emergent and non-emergent cases is well documented.

In the emergency room (ER), patients in sepsis, who do not have existing access, can greatly

benefit from the use of IO access to deliver fluids and medications quickly. Delaying treatment

for peripheral or central venous access has the potential to increase the risk of morbidity and

mortality and is unnecessary when IO access is readily available (Philips, L. et. al., 2010).

Currently, the sepsis bundle includes fluid resuscitation at 30mL/kg to be completed within the
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first three hours of presentation but does not have any provisions for the use of IO access

(Surviving Sepsis Campaign, 2015).

Research Question

In adult septic shock patients treated in the emergency department (P), how does

intraosseous (IO) access for fluid resuscitation (I) compared to intravenous (IV) access (C) affect

mortality (O) within the first 24 hours (T)?

Literature Review

IO access was utilized extensively during World War II after being introduced as a way to

perform transfusions as well as deliver medications and fluids (Day, 2011). After the

development of the plastic peripheral intravenous catheter, IO access research was limited until

the late 1970s (Day, 2011). IO access is currently routinely used and recommended for use in the

pediatric population as well as endorsed by the American Heart Association for routine use in

cardiac arrest patients and multiple professional societies recognize that intraosseous 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 necessary

fluids and medications (Philips, L. et. al., 2010).

The military has provided more research in recent years to include case studies and level

I-II evidence as use of IO access has been essential for use in the Iraqi War Theater. Civilian data

regarding IO access is limited but includes level I-III evidence, primarily in regards to trauma

patients in the ED and hypovolemic states. As severe sepsis and septic shock are hypovolemic

states, the data collected is applicable to this pathology.

Data gathered from the military in recent years includes hypovolemia secondary to

trauma with IO insertion being performed both pre-hospital and in the emergency department of
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deployed medical facilities. Success rates for IO access were found to be between 85-97% with a

recent analysis of 1000 uses of IO access from a 7-year period between 2006 and 2013 during

combat operations in Afghanistan concluded that IO access has a valuable role in resuscitation of

the critical patient with low complications rates (Lewis, P. & Wright, C., 2015, p. 463). Literature

consistently demonstrates ease of use of IO devices and high success rates after minimal training

and education.

Regarding speed of insertion, with minimal training, IO is 6 minutes faster and easier to

achieve than central vascular access and requires less training (Joanne, 2015, P 172). Multiple

studies site a higher first time insertion success rate and faster procedure time with IO access

compared to CVC, however it should be noted that IO is not a replacement for CVC (Leidel,

2012, P 40). Definitive access will still need to be obtained within 24 hours as that is the limit

according to manufacturer instructions for IO devices to remain in place.

Some potential complication includes extravasation from dislodgement, iatrogenic

fracture, growth plate injury, infection, fat emboli, compartment syndrome, and osteomyelitis

(Phillips, 2011, P 87). Complications are short term and rare with limited evidence available

regarding long term complications of IO use. Contraindications to use include long bone

fracture, severe bone disease and femoral or saphenal venous cut-down in the same limb (Craiu,

2014).

One of the main benefits of utilizing IO access in hypovolemic and shock states is

because the IO space is not compromised during shock (Lowther, 2011, P 36). It should also be

noted that The International Liasion Committee on Resuscitation and the European Resuscitation

Counsel advocate for IO over CVC or endotracheal drug administration (Anson, 2014, P 1015).
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Research data has shown consistently that administration of fluids and drugs is equal

when given either by IO or IV access. In some instances, data has shown that fluids and drugs

administered through the IO space reach the central circulation as quickly as central lines and

faster than peripheral lines (Phillips, 2011, P 86).

Many facilities lack regulations regarding IO use in the ER as sited in several studies

including a cross-sectional study conducted in Danish EDs. While IO devices are available in the

majority of EDs, guidelines regarding use as well as training are lacking (Molin, 2010). While IO

access is included in the 2010 guidelines for cardiopulmonary resuscitation, there are no national

guidelines available regarding IO access use in sepsis. IO use is currently utilized primarily in

the pre-hospital environment with each organization having their own guidelines usually

reserving IO access for resuscitation.

Current limitations in the data include that randomized controlled trials are difficult to

obtain as IO use in the ED is limited (Hallas, 2016, P 262). Much of the statistical data obtained,

especially regarding drug and antibiotic administration rates, comes from animal studies as

opposed to human studies for ethical reasons. Another limitation is in regards to limited data

available regarding cost/benefit analysis resulting in the inability to determine overall cost

effectiveness. It should be noted that the cost of IV needles is significantly less than that of IO

needles (Joanne, 2015, P 174).

EBP Decision

Based on the evidence, IO access is a highly underutilized and effective means of

obtaining vascular access for fluid resuscitation in sepsis as well as other shock and hypovolemic

states. The majority of the literature agrees that IO access should be used when obtaining IV or

CVC access is difficult or impossible, or would delay treatment (Lowther, 2011, P 36). It is
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recommended that IO access be utilized in septic shock in the ER to ensure that fluid

resuscitation is not delayed and to thereby improve morbidity and mortality rates.

Conceptual Basis

The Nursing Process Discipline Theory developed by Ida Jean Orlando will be used to

guide this project and implementation of best practice in addition to the Plan-Do-Study-Act

model. The theory looks to the nurse to find out and meed the patients immediate needs for

help (Nursing process theory, 2016). Patients are not always able to communicate their needs so

it is the responsibility of the nurse to determine what the patient needs to facilitate improvement

in the patients condition and/or outcomes.

The nurse must be able to assess the patients distress during septic shock in determining

if intraosseous or intravenous access (either through peripheral IV or central venous catheter) is

in the best interest of the patient based on the nursing assessment of that patient. It is the function

of the professional nurse to need the patients immediate need, which in this situation is fluid

resuscitation and access to administration of medication as well as blood sampling in a timely

manner, and determine the best course of action.

Procedures

Organizational consents required prior to project implementation includes approval by

the Quality Improvement committee as well as East Texas Medical Center hospital

administration. At the lower level, approval will need to be sought from the emergency

department director and clinical nurse education as they will be directly involved in coordinating

and supporting this project. This project will be approved by the institutional review board (IRB)

if needed.
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Data will be collected from hospital electronic medical records and recorded using

Microsoft Excel Spreadsheet for data reporting and statistical analysis. Data will be collected and

reported as covered by HIPPA for the use in quality improvement purposes. Data gathered will

be protected on the hospitals secure server and no personal patient identifying information will

be recorded.

This project does not require funding by an external service of grant and will be

conducted at minimal expense to the facility. Data regarding cost will be kept as the project is

implemented and reported in a cost-benefit analysis at project completion.

The Plan-Do-Study-Act (PDSA) will be utilized as the model guiding this project

proposal utilizing the PDSA Worksheet for Testing Change from the Institute for Healthcare

Improvement.
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Data will be gathered and statistically analyzed to guide quality improvement regarding

the use of IO access in the ED during septic shock and severe sepsis.

Summary

IO access is highly underutilized in the ER in providing timely access to provide fluid

resuscitation in patients who present in septic shock without current access. In addition to

providing fluid resuscitation, IO access is also an effective route for blood sampling as well as

medication administration with few complications and fast insertion times. Implementation of

use in the ER will benefit patients with decreased mortality rates with data being gathered via

chart reviews and documented and analyzed using Microsoft Excel for continued quality

improvement.
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