IO Medications
Question# 818
Question concerning administration of certain medications via IO route. It was taught in school that anything that can be given IV can also be given IO. Certain of our medications that we can give can only be administered via IV route according to certain directives (ex: dextrose, dopamine). In certain circumstances where IV access is unobtainable and IO access is obtained, can we still administer "IV only" drugs IO or a BH patch would be mandatory in this case?
Answer:
In short, any medication that is given intravenously can be given via the IO route; at the same doses.
It is important to follow the Advanced Life Support Patient Care Standards (ALS PCS) as it outlines the autonomous delegated medical acts paramedics can perform - even the routes of medication administration. That said, if you would like a standing order that falls outside of the ALS PCS a verbal order is required, and the Base Hospital Physicians (BHPs) are happy to engage in these patient-centred discussions.
Having said that, given the preciseness needed to titrate dopamine, it would be difficult to administer this medication via an IO - especially if a buretrol or similar flow control device is used (e.g. 60 gtt set, control-a-flow, etc.). There is also a concern for tissue destruction from extravasation.
With respect to dextrose, the IO route can be used in patients with difficult IV access who are hypoglycemic, so long as the indications for IO access are met. Thank you for highlighting this gap, and we will bring this suggestion forward for future potential changes to the ALS-PCS.
As you mentioned, sometimes a patient’s underlying pathology (e.g. shock state, hypovolemia, obesity, IV drug abuse, end-stage renal disease, etc.) can make it difficult to place an IV. While an IO is a safe and rapid route to administer drugs and fluids, and even draw most labs from, an IV is the preferred route of venous access.
The AHA and ILCOR guidelines prioritize IV over IO during resuscitation, as this route of medication administration appears to have higher efficacy in achieving ROSC, with positive effects of ultimate patient outcome.
One final thought to consider as well is that given the intermedullary space, flow rates through an IO are slower. A 15 g tibial IO has an approximate flow rate to gravity of 70 mL/min, and a humeral IO has an approximate flow rate to gravity of 80 mL/min.
As a comparison, and 16 g IV has an approximate flow rate to gravity of 150 mL/min – more than double! Interestingly, an 18 g IV has an approximate flow rate to gravity of 100 mL/min. The difference between these may not seem important at first, and for most routine medication administration, but this flow difference makes a big difference for major resuscitations. The use of a pressure infuser can help overcome this.
As a reminder, as per the ALS PCS clinical considerations, calcium gluconate should only be administered in an IV/IO/CVAD that is running well.
If IV access is not readily obtainable or delayed, and you elect to initiate an IO, please record your thought process in the remarks section.
It is important to follow the Advanced Life Support Patient Care Standards (ALS PCS) as it outlines the autonomous delegated medical acts paramedics can perform - even the routes of medication administration. That said, if you would like a standing order that falls outside of the ALS PCS a verbal order is required, and the Base Hospital Physicians (BHPs) are happy to engage in these patient-centred discussions.
Having said that, given the preciseness needed to titrate dopamine, it would be difficult to administer this medication via an IO - especially if a buretrol or similar flow control device is used (e.g. 60 gtt set, control-a-flow, etc.). There is also a concern for tissue destruction from extravasation.
With respect to dextrose, the IO route can be used in patients with difficult IV access who are hypoglycemic, so long as the indications for IO access are met. Thank you for highlighting this gap, and we will bring this suggestion forward for future potential changes to the ALS-PCS.
As you mentioned, sometimes a patient’s underlying pathology (e.g. shock state, hypovolemia, obesity, IV drug abuse, end-stage renal disease, etc.) can make it difficult to place an IV. While an IO is a safe and rapid route to administer drugs and fluids, and even draw most labs from, an IV is the preferred route of venous access.
The AHA and ILCOR guidelines prioritize IV over IO during resuscitation, as this route of medication administration appears to have higher efficacy in achieving ROSC, with positive effects of ultimate patient outcome.
One final thought to consider as well is that given the intermedullary space, flow rates through an IO are slower. A 15 g tibial IO has an approximate flow rate to gravity of 70 mL/min, and a humeral IO has an approximate flow rate to gravity of 80 mL/min.
As a comparison, and 16 g IV has an approximate flow rate to gravity of 150 mL/min – more than double! Interestingly, an 18 g IV has an approximate flow rate to gravity of 100 mL/min. The difference between these may not seem important at first, and for most routine medication administration, but this flow difference makes a big difference for major resuscitations. The use of a pressure infuser can help overcome this.
As a reminder, as per the ALS PCS clinical considerations, calcium gluconate should only be administered in an IV/IO/CVAD that is running well.
If IV access is not readily obtainable or delayed, and you elect to initiate an IO, please record your thought process in the remarks section.