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Injury Extra 42 (2011) 173–177

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Injury Extra

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Case report

A severe complication following intraosseous infusion used during resuscitation

of a child

a, a a b

L.A.K. Khan *, R.E. Anakwe , A. Murray , Y. Godwin

a

Department of Orthopaedic Surgery, Royal Hospital for Sick Children, 9 Sciennes Road, Edinburgh EH9 1LF, United Kingdom

b

Department of Plastic Surgery, Royal Hospital for Sick Children, 9 Sciennes Road, Edinburgh EH9 1LF, United Kingdom

undertaken. The initial compartment pressure recording was

A R T I C L E I N F O

55 mmHg and the patients diastolic blood pressure was 50 mmHg

Article history: giving a difference in pressure (DP) of À5 mmHg supporting a

Accepted 12 May 2011 diagnosis of compartment syndrome.

Four compartment fasciotomies were then undertaken through

a routine two incision technique. As the patient’s cardiovascular

status was too unstable for transfer to an operating theatre this

1. Case report

procedure was carried out in the paediatric intensive care unit. The

findings of the procedure were: globally tight muscles, the muscles

An eleven year old boy who had previously been fit and well

in the anterior compartment appeared dark with little bleeding

collapsed in a public place. Bystanders trained in basic life support

and diminished contractility. The muscles in the other three

started resuscitation and the patient was transported to a

compartments appeared tight but otherwise unremarkable. It was

paediatric Accident and Emergency department by ambulance.

noted that after fasciotomies dorsiflexion of the ankle improved.

On arrival in the resuscitation room the patient was noted to be

The fasciotomies were left open and the leg was dressed and the

in ventricular fibrillation with no palpable peripheral pulses. A

patient continued to be supported in the PICU.

defribillator delivered one shock, which resulted in sinus rhythm

Seventy-two hours after admission and when cardiac status

being restored. The patient was noted to have poor peripheral

allowed, the patient underwent a formal second look and

perfusion with cool peripheries and attempts at obtaining vascular

debridement under joint care of the orthopaedic and plastic

access were at first unsuccessful. An intraosseous needle (15 G EZ-

surgical teams. It was evident that there was full thickness skin

IO) was then inserted through the superficial border of the right

loss, subcutaneous tissue loss and boney necrosis of the proximal

tibia using the power driver technique, it was noted that insertion

tibia, surrounding an area corresponding to the entry point of the

was routine with no complications and fluid flowed easily with no

cannula. The soft tissue injury was in keeping with a chemical

resistance. The intraosseous needle was used to infuse an

injury with evidence of an extravasation injury, spreading from the

immediate bolus of 500 ml of normal saline followed by adrenaline

insertion point of the cannula in the proximal tibia radially and in

at a rate of 1 mcg/kg/min. At this stage both central and peripheral

an outward direction from deep to superficial. Examination of the

vascular access were successfully obtained.

anterior compartment revealed that 80% of the proximal tibialis

The patient was then transferred to the Paediatric Intensive

anterior muscle was necrotic with only the distal 20% of the muscle

Care Unit (PICU) for ongoing care. During the next 24 h the

remaining viable. 100% of the extensor digitorum muscle was

intraosseous needle was used to infuse adrenaline, calcium and

potassium. necrotic. The anterior tibial neurovascular bundle was intact. In the

deep posterior compartment the proximal muscle bellies of tibialis

On the day after admission it was noted by the nursing staff that

posterior and flexor digitorum longus were necrotic. In the

the there was swelling and echymosis around the intraosseous

superficial posterior compartment the soleus muscle was necrotic

needle insertion site. The infusions were immediately stopped and

in its proximal section (corresponding to the area of tibia affected).

an orthopaedic opinion was requested by the PICU staff.

The heads of gastrocnemius were viable but there was evidence of

The orthopaedic surgeon who reviewed the patient noted that

chemical injury on the deep surface of this muscle, again

the right lower leg was swollen on inspection, firm to palpation

corresponding to the area where extravasation would have

and that the peripheral pulses were weak although the capillary

occurred. The posterior tibial artery and vein were pulsatile. The

refill was less than 2 s. There was also restricted dorsiflexion of the

contents of lateral compartments appeared normal. All necrotic

ankle joint. A provisional diagnosis of compartment syndrome was

1 muscle and skin were excised. Thorough washout was undertaken

made and immediate compartment pressure monitoring was

and the wounds were re-dressed and the patient was returned to

the PICU.

* Corresponding author. Day six post-injury, the patient was returned to theatre for a

E-mail address: [email protected] (L.A.K. Khan). third look, at this procedure further necrosis of the proximal skin

1572-3461 ß 2011 Elsevier Ltd. Open access under the Elsevier OA license. doi:10.1016/j.injury.2011.05.015

174 L.A.K. Khan et al. / Injury Extra 42 (2011) 173–177

Fig. 1. Intraoperative photograph taken at the fourth inspection, an area of Fig. 3. Intraoperative picture showing the appearance of the lower leg after

osteonecrosis is seen in the proximal tibia corresponding to the area of intraosseous gastrocnemius flap and lateral skin grafts. An area of exposed bone is seen at the

needle placement. proximal tibia.

was noted and further debridement was undertaken of the skin, free flap was planned with boney debridement as necessary.

along with the remaining 20% of tibialis anterior in the anterior Unfortunately, the patient had a further cardiac episode at

compartment. A vacuum assisted closure (VAC) dressing was also anaesthetic induction. The decision was made to do the shortest

applied at the end of this procedure. most appropriate procedure. The options were either above knee

A fourth review was undertaken 48 h later. The osteonecrosis of amputation or boney debridement/acute bone shortening and a

the proximal tibia was clearly demarked with no further medial gastrocnemius flap. The second option was chosen. A

progression (Fig. 1). In the anterior compartment only the distal medial gastrocnemius flap was then used to cover the soft tissue

tendon of tibialis anterior remained along with the anterior tibial defect over part of the anterior aspect of the proximal tibia leaving

neurovascular bundle. The lateral compartment was still intact. a 2 cm strip of exposed bone and periosteum (Figs. 2 and 3). Split

The remaining contents of the deep posterior compartment were skin grafts were used to cover the gastrocnemius flap and lateral

as described before and viable. In the superficial posterior fasciotomy wounds. At further inspection, to aid soft tissue

compartment the gastrocnemius muscle was viable, with no coverage, two centimetres of proximal tibia were excised in the

progression of injury, as was the distal half of the soleus muscle. region of the osteonecrotic area using a transverse shortening

The progression of tissue loss and injury therefore seemed to have osteotomy and this was held with an Hoffman external fixator

halted. (Stryker Ltd, Leeds, UK) (Figs. 4–6). The patient was fitted with an

Further investigation was undertaken to allow operative implanted cardiac defribillator and after a period of in-patient

planning with respect to either reconstruction or amputation of rehabilitation was able to be discharged home. Unfortunately the

the limb. The patient then underwent an MRI scan which osteotomy was complicated by an infected non-union (Figs. 7 and

confirmed osteonecrosis of the proximal tibia and a CT arteriogram 8) and 11 months after the initial presentation the patient had to

demonstrated intact popliteal, peroneal, anterior tibial and undergo debridement and application of a circular Ilizarov frame.

posterior tibial arteries. Reconstruction with a latissmus dorsi Eighteen months after the initial presentation there are now signs

Fig. 2. Intraoperative picture showing formation of a medial gastrocnemius flap to Fig. 4. Intraoperative picture after excision of 2 cm of proximal tibia during the

provide soft tissue cover to the proximal tibia. tibial shortening procedure.

L.A.K. Khan et al. / Injury Extra 42 (2011) 173–177 175

Fig. 7. AP radiograph showing evidence on non-union 8 months after tibial

shortening osteotomy.

Fig. 5. Final appearance of the lower leg after the tibial shortening.

of some bone bridging across the osteotomy site (Figs. 9 and 10).

The infection appears to have resolved with treatment but bony

healing is, however, far from complete and union may not be

achieved. Further surgery with bone grafting and synthetic

osteogenic products is being considered. The option of through-

knee amputation to provide optimal functional outcome is being

Fig. 6. Radiograph of the lower leg after tibial shortening and application of external Fig. 8. Intraoperative picture showing arfea of infected non-union in the proximal fixator. tibia.

176 L.A.K. Khan et al. / Injury Extra 42 (2011) 173–177

Fig. 9. Appearance of the leg after application of the circular frame.

Fig. 10. AP radiographs showing appearance of the tibia after 7 months treatment in

a circular frame with evidence of bone bridging across the osteotomy site.

discussed as foot and ankle function is poor and distal sensation

patchy.

2. Discussion canal into the soft tissues. An experimental study in dogs by

4

Gunal et al. showed that even when the intraosseous needles

The use of intraosseous needles and infusion is valuable in were cemented in place correctly there was evidence of

resuscitation of both paediatric and adult patients where there is extravasation of fluid into the soft tissues which was shown

difficulty in obtaining vascular access and immediate infusions of fluoroscopically using radio-opaque dye. Infusion of greater than

drugs and or fluids is required. Although potentially life saving, this 350 ml led to an increase in measured compartment pressure

technique is not without complications. At present there is no clear which was proportional to the amount of fluid infused. In the

consensus from the literature regarding: the length of time an case we describe, the intraosseous infusion was over a period of

intraosseous needle should remain in place, the maximum rate or 24 h and included a 500 ml bolus of fluid and then on-going

volume that should be infused through this route and what drugs infusions. This may have contributed to the development of

should be avoided or be used in altered concentrations through compartment syndrome.

2–5

this route. Musculoskeletal complications as a result of Chemical toxicity to bone and or soft tissues is another possible

intraosseous infusions are rare and occur in less than one percent explanation for the complications observed. The intraosseous

3

of patients. Reported complications include: compartment catheter was used to infuse adrenaline, calcium, potassium and

5–11 3

syndrome and resultant amputation, osteomyelitis and possible other drugs. Intraosseous adrenaline has previously been

12

myonecrosis. implicated in causing skin necrosis and osteomyelitis leading to

3

We report a patient who had a severe complication as a result of bony destruction. It is possible that the skin necrosis and

intraosseous infusion, the cause of the complications is unclear and osteonecrosis seen in this case was a result of local toxicity from

may be attributed to a combination of factors. One explanation is a adrenaline and or one of the other drugs infused.

direct pressure effect from extravastion of fluid into the soft tissues Intraosseous needle placement for infusion is a potentially

13

either from incorrect placement or from dislodgement of the lifesaving aid during resuscitation and current guidelines state

catheter, however, the insertion of the needle was reported as that it is a suitable method for administration of all drugs used

being routine and there was no difficulty reported in infusing fluid during resuscitation where there is a delay in establishing

through the needle. intravenous access. This case report serves to highlight some

Another explanation is that due to pressure from a high rate potential complications associated with these methods and

of infusion or as a consequence of a large total volume infused reminds readers that careful observation of the limb is required

there could be secondary extravasation from the intraosseous during prolonged intraosseous infusion so that potential compli-

L.A.K. Khan et al. / Injury Extra 42 (2011) 173–177 177

6. Moscati R, Moore GP. Compartment syndrome with resultant amputation

cations are avoided. Further work is needed to develop recom-

following intraosseous infusion. Am J Emerg Med 1990;8(September

mendations for maximum duration, dose, volume and rates for (5)):470–1.

intraosseous infusion. 7. Galpin RD, Kronick JB, Willis RB, Frewen TC. Bilateral lower extremity com-

partment syndromes secondary to intraosseous fluid resuscitation. J Pediatr

Orthop 1991;11(November–December (6)):773–6.

8. Gayle M, Kissoon N. A case of compartment syndrome following intraosseous

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