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Intra-osseous-access-associated lower limb compartment syndrome in a critically injured paediatric patient

2018; Lippincott Williams & Wilkins; Volume: 35; Issue: 12 Linguagem: Inglês

10.1097/eja.0000000000000873

1365-2346

Jake Turner, Karl‐Christian Thies,

Trauma Management and Diagnosis

Editor, A 12-month-old with multiple injuries developed a left lower limb compartment syndrome following intra-osseous cannula insertion into the anterior tibia. Intra-osseous cannulae have become increasingly popular for fluid resuscitation in critically unwell children who often have poor peripheral perfusion and present with difficult intravenous access. Informed consent for publication was obtained from the mother. The child was a rear seat passenger involved in a road traffic collision and suffered multiple injuries despite being appropriately restrained in an infant's car seat. The prehospital critical care team found the infant in traumatic cardiac arrest and the airway was secured with a laryngeal mask. A suspected tension pneumothorax on the left side was treated successfully by needle thoracostomy and an intra-osseous cannula (EZ-IO 15 mm; Teleflex, Wayne, Pennsylvania, USA) was inserted into the flat anteromedial surface of the left tibia, 3 cm below the tibial tuberosity for fluid resuscitation. The cannula was secured with an EZ-IO Stabilizer Kit (Teleflex) to minimise the risk of dislocation. After the return of spontaneous circulation the infant was airlifted to Birmingham Children's Hospital. On admission, in hypovolaemic shock, immediate transfusion of blood products was required. Two boluses of packed red blood cells 10 ml kg−1 were given with a hand-held 20-ml syringe through the intra-osseous needle, based on an assumed bodyweight of 10 kg. Due to poor peripheral perfusion, peripheral venous access could not be obtained in the emergency department (ED) and a second intra-osseous cannula was inserted into the right tibia. These measures allowed the physiology to stabilise and enabled a whole body computerised tomography (CT) scan to be undertaken. The CT scan revealed a large left-sided intraventricular bleed, an extradural haematoma (EDH) with midline shift and a contained liver rupture. After conclusion of the CT scan, the infant was taken to the operating room for evacuation of the EDH. Before the operation the trachea was intubated and a 4.5 French-gauge catheter introducer sheath was placed into the right internal jugular vein under ultrasound guidance. Shortly after the start of the procedure, a routine check of the intra-osseous sites revealed a tense swelling of the left calf suggestive of compartment syndrome. Fluid infusion through the left tibial intra-osseous cannula was discontinued and the cannula removed. The plastic surgeon on duty reviewed the swollen calf and opted to perform a fasciotomy whilst the craniotomy continued. All four compartments were released and in the deep posterior compartment a haematoma and tissue oedema were identified. The surgeon identified a small hole in the posterior cortex of the tibia in communication with the deep posterior compartment, located opposite the intra-osseous insertion site. All compartments were left open for delayed closure. The operation continued uneventfully and for further therapy the infant was transferred to the ICU where it was evident that perfusion to the lower limb had been restored following the fasciotomy. Several international guidelines recommend intra-osseous access as the preferred route for fluid resuscitation in the acutely unwell child in whom intravenous access is futile or has been unsuccessful.1–3 Intra-osseous access has also been described in a case series of elective anaesthesia for children with difficult venous access.4 Its complication rate is generally perceived to be low, although much of this evidence is based upon small series and case reports.5–8 Although a more recent, larger, retrospective study recognised that intra-osseous complication rates are probably higher than previously reported,9 the rate of compartment syndrome associated with intra-osseous access remains very low at 0.6%. The deep posterior compartment of the calf is behind the posterior cortex of the tibia and contains the major neurovascular structure supplying the lower leg (Fig. 1). This compartment is likely to be the first to be entered by a through-and-through intra-osseous-cannula insertion, potentially giving rise to significant sequelae, particularly for those needing pressurised infusions. A recent case report demonstrated a narrow margin of safety for correct intra-osseous positioning with a mean medullary diameter of 10 mm in 1 to 12 month olds,10 making a through-and-through placement of a 15-mm intra-osseous cannula entirely possible.Fig. 1: Cross section of the lower leg. The deep posterior compartment is located directly posterior to the tibia. Compartment syndrome in this compartment is difficult to detect as it is well covered by surrounding tissue.There are few case reports highlighting the risk of compartment syndrome associated with intra-osseous access.10–13 However, we feel that this complication warrants attention; children needing intra-osseous access are critically unwell and unable to communicate discomfort whilst their medical teams are concentrating on essential clinical interventions rather than watching for compartment syndrome. Also, intra-osseous access is not regularly used in anaesthesia and the presence of prehospital inserted intra-osseous-access risks omission in handovers from the ED to the operating theatre anaesthetist. We suggest a number of recommendations in children to help prevent and identify this rare complication of intra-osseous access: Avoid excessive force while inserting: allow the EZ-IO power driver to do the work; be cognisant of the narrow medullary cavity, needle tip position and puncture the flat tibial surface at 90°. Never manipulate the intra-osseous cannula: use specifically designed fixation devices such as the EZ-Stabiliser dressing and three-way extension sets. Frequently review the insertion site for swelling and maintain a high index of suspicion for compartment syndrome in sedated or anaesthetised children as early signs of pain will be masked. Acknowledgements relating to this article Assistance with the letter: none. Financial support and sponsorship: none. Conflicts of interest: none.