LESSON OF THE WEEK: Amputation and intraosseous access in infants

Author(s): Colm C Taylor and N M P Clarke

Source: BMJ: British Medical Journal, Vol. 342, No. 7810 (11 June 2011), pp. 1308-1309
Published by: BMJ
Stable URL: https://www.jstor.org/stable/23050110
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 PRACTICE

LESSON OF THE WEEK

Amputation and intraosseous access in infants

Colm C Taylor, N M P Clarke

notable mottling to mid-calf level (fig 1). Bilateral poste

Southampton General Hospital,
Tremona Road S016 6YD.UK
Correspondence to: N M P Clarke
ortho@soton.ac.uk
Cite this as: BM) 2011;342:d2778
doi: 10.1136/bmj.d2778
Place intraosseous needles carefully and
limit fluid infusion to avoid limb ischaemia in
children
Vascular access in critically ill children is a priority for
emergency administration of fluid and therapeutic agents.
Intraosseous access is an alternative when attempts at
rior tibial fractures were noted at the level of intraosseous
access. The patient was taken to theatre on day 12; all lower
limb compartments were explored but were non-viable and
an amputation was performed below the knee. She had no
further sequelae and was discharged at one month. At six
months, her right lower limb had no deficit and extension
at the left knee was maintained.

venous access fail.1 The proximal tibia is the preferred

site for intraosseous needle insertion, with an accessible Case 2
subcutaneous cortex. Manual insertion of the intraosseous A17 month old boy attended a local hospital 48 hours after
needle can be supplemented with approved impact driven a scald injury to the chest with a truncal rash and deterio
and power driven needle systems.2 rating consciousness. Bilateral proximal tibial intraosseous
Intraosseous access has low failure and complication access was established with a power driven system. Resus
rates,3 but compartment syndrome has been reported in citation included 250 mL normal saline/dextrose saline,
association with this procedure,4 and preventive measures 300 mL 4.5% albumin solution, 8.4% sodium bicarbonate
have been recommended.5 Three cases of amputation have calcium gluconate, and whole blood. Fluid distribution
been reported, preceded by clinical features of compartbetween the limbs was unclear, but intraosseous infusion
ment syndrome within a few hours of admission.6 was increasingly difficult on the right side within 30 min
We describe two cases of leg amputation after intra utes, the left being used exclusively after this. Total infused
osseous infusion to emphasise the risk of limb ischaemia volume was 7 30 mL. On transfer to the paediatric intensive
during paediatric resuscitation by this route. care unit, the left leg was tense and pulses were impalpable
bilaterally. During treatment for septicaemia, the patient's
Case reports left limb gradually demarcated to proximal calf at the lateral
Casel aspect, while perfusion returned on the right. A below knee
A 5 month old girl was resuscitated at a local hospital for was performed on day 13, when all muscle com
amputation
pulseless cardiac arrest caused by unrecognised congenital
partments were non-viable. He was discharged at six weeks.
diaphragmatic hernia. Emergent bilateral proximal
Thetibial
limb had made good progress by six months, with early
intraosseous access was achieved with a power driven sys fitting; unfortunately early signs of distal tibial
prosthetic
tem. Resuscitation included 1:10 000 adrenaline solution,
physeal arrest were seen at the right lower limb.
200 mL normal saline, 15 mmol sodium bicarbonate, 10
Discussion
pg/kg dopamine infusion, and whole blood. In total over
Local tissue necrosis and osteomyelitis were described in
400 mL of solution was infused, predominantly through
the earliest
the left leg. She was transferred for laparotomy, and sub report on the complications of intraosseous
infusion in 1945.7 Sternal and tibial access was preferred
sequent ventilatory and inotropic support in the paediat
and pale
ric intensive care unit. Both distal lower limbs were contemporary guidelines emphasised careful needle
but not tense on admission; by day seven, the right
insertion
limb and avoiding prolonged infusion times.
Several recent case reports have described compart
was perfused but her left leg had become demarcated with
ment syndrome after intraosseous access. Large infusion
volumes have been implicated, and animal studies report
microcirculatory fluid leak in both dose-dependent and
time-dependent mechanisms.8 Other potentiating factors
include needle dislodgement, penetration through the
posterior cortex, and leaking through previous potentiat
ing access sites.5 Both patients described here had pro
longed resuscitation incorporating large amounts of fluid
and potentially irritating therapeutic solutions. Failure
of peripheral access necessitated continued use of intra
osseous infusion, potentiating the risk of extravasation,
particularly as venous return is greatly diminished in
paediatric resuscitation. Guidelines regarding intraosseous
infusions were published by the American Academy of
Pediatrics in 1994; these suggested limiting the time of
Fig
Fig 11
11Demarcation
Demarcationbefore
before
amputation
amputation infusion, securing definitive peripheral access, avoiding

1308 BMJ111 JUNE 20111 VOLUME 342

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 PRACTICE

bmj.com
bmj.com Previous
Previousarticles
articles chemical necrosis and peripheral hypoperfusion were
in this
this series
series potentiating factors. Where ventilation and fluid resusci
tation is a priority, impending compartment syndrome is
O When
When aa cyst
cystisisnot
nota a
easily missed. Early recognition allows our preferred option
cyst
of subcutaneous fasciotomy in the young child. Adherence
(BMJ 2011;342:d2844)
to the principles detailed in the BMJ almost 70 years ago (fig
O Rebound hypoxaemia
2)13 of careful needle placement, splinting, limited length
after administration
of infusion and repeated monitoring of the limb will help
of oxygen in an acute
avoid this devastating complication.
exacerbation of chronic Competing interests: All authors have completed the Unified Competing
obstructive pulmonary Interest form at www.icmje.org/coi_disclosure.pdf (available on request from
the corresponding author) and declare: no support from any organisation for
disease
the submitted work; no financial relationships with any organisations that
{BM12011;342:d1557)
(BMJ 2011;342:d1557) might have an interest in the submitted work in the previous 3 years; no other
relationships or activities that could appear to have influenced the submitted
O Life threatening
work.
myelotoxicity secondary Fig 2 | Intraosseous access13 Provenance and peer review: Not commissioned; externally peer reviewed.
to azathioprine Patient consent obtained.

in a patient with infusion pumps, and careful observation of the limb dur 1 Advanced Life Support Group. Advanced paediatric life support, 4th
ing early infusion.9 ed. Wiley-Blackwell, 2005.
atopic eczema and LuckRP,Haines
2 LuckRP, HainesC,C,Mull
MullCC. Intraosseousaccess./fmergMed
CC. Intraosseous access. I Emerg Med
normal thiopurine Progression to amputation was first described in 1990, 2010;39:468-75.

methyltransferase activity
(e/W;2011;342:d1417)
O Pituitary infarction:
a potentially fatal
cause of postoperative
hyponatraemia and ocular
palsy
(BMJ 2011;342:d1221)
when a 3 month old child had an amputation at the knee DH. Current
3 Fiser DH. Current concepts.
concepts. Intraosseous
Intraosseous infusion.
infusion.NNEngll
Engl I Med
Med
1990;322:1579-81.
after prolonged resuscitation.6 A further three cases have
4 Galpin RD, Kronick|B,
Kronick)B, Willis RB, FrewenTC. Bilateral lower extremity
been described, all during prolonged infusion, with the ear compartment syndromessecondary to intraosseous fluid resuscitation.
IPediatrOrthop 1991;11:773-6.
liest recognition of compartment syndrome at 2.5 hours into
5 Atanda A |r, Statter MB. Compartment syndrome ofthe leg after
resuscitation. Three patients had infusion of potentially irri intraosseous infusion: guidelines for prevention, early detection, and
treatment. Am
treatment. AmiI Orthop (BelleMeadNfl
Orthop (Belle Mead NJ)2008;37:198-200.
2008;37:198-200.
tating solutions, including inotropes, sodium bicarbonate,
6 Moscati R, Moore GP. Compartment syndrome with resultant
and calcium. Two patients were transported with intraos amputation following intraosseous infusion. Am
AmJEmerg
I EmergMed
Med
seous needles in situ. 1990;8:470-1.
7 Committee on Pediatric Emgency Medicine. Intraosseous infusions. In:
Although power driven needle systems are rapid in American Academy of Pediatrics reference guide. Reference number
establishing access, the potential for inaccurate needle RE9260.6th ed. American Academy of Pediatrics, 1993.
Gunal I, Kose N, Gurer D. Compartment syndrome after intraosseous
8 Giinal intraosseous
placement remains, because children's tibia have a small infusion: an experimental study in dogs.1 PediatrSurg
cross-sectional area available for effective access.910 Result 1996;31:1491-3.
TocantinsLM,
9 Tocantins LM, O'Neill
O'Neill JF.
JF. Complications
Complications of
of intra-osseous
intra-osseous therapy.
therapy. Ann
Ann
ing paediatric tibial fractures, as in case 1, have previously Surg 1945;122:266-77.
been reported, and particular care needs to be taken with
10 Davidoff J, Fowler R, Gordon D, Klein G, KovarJ, Lozano M, etal. Clinical
evaluation of a novel intraosseous device for adults: prospective, 250
infants.11 Insecure access and needle dislodgement allowed
patient, multi-centertrial.yf/MS
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unrecognised extravasation in case 2; securing an accu11 La Fleche FR, Slepin Mj,
M|, Vargas I.
I, Milzman
Milzman DP.
DP. Iatrogenic
Iatrogenic bilateral
bilateral tibial
tibial
fractures after intraosseous infusion attempts in a 3-month-old infant.
rately placed needle is especially important during transfer,
Ann Emerg Med 1989;18:1099-101.
and use of a threaded needle has been suggested.12 12 Gayle M, Kissoon N. A case of compartment syndrome following
We conclude that fluid extravasation, exacerbated by intraosseous infusions. PediatrEmerg Care 1994;10:378.
13 Bailey H. Bone marrow as a site forthe reception of infusions,
tibial fracture and needle dislodgement during transporta transfusions and anaesthetic agents. BMJ 1944;i:181-2.
1944;1:181-2.
tion, caused limb ischaemia in these two patients. Local
Accepted: 15 March 2011

ANSWERS TO ENDGAMES, p 1317. For long answers go to the Education channel on bmj.com

PICTURE QUIZ CASE REPORT An unusual cause of fever of unknown origin

A newborn with hypotonia and abnormal fades
1 Myotonic dystrophy.
2 The inability to release a firm hand grip quickly (grip myotonia),
which would be apparent on shaking the mother's hand.
3 Respiratory and nutritional support.
1 The differential diagnosis of fever of unknown origin includes infections (such
as tuberculosis), cancers (such as non-Hodgkin's lymphoma), collagen vascular
conditions (such as systemic lupus erythematosus), drugs, and other causes.
2 On the basis of his recurrent spikes of temperature of 39°C or more, evanescent
rash, sore throat, arthralgia, neutrophil leucocytosis, lymphadenopathy,
hepatomegaly, deranged liverfunction tests, and a high ferritin concentration

h Moleculargenetics. the most likely diagnosis is adult onset Still's disease.

3 Non-steroidal anti-inflammatory drugs are typically used as first line
5 A high risk of neonatal mortality and serious disability if she
survives. treatment, although most patients do not respond to these drugs alone and
rapid escalation to corticosteroids is often the next step. Disease modifying
antirheumatic drugs and new biological agents may be used in refractory cases,
will depend
but this will depend on
on the
the extent
extent and
and severity
severityof
ofthe disease. Treatment
the disease. Treatment is
is
STATISTICAL QUESTION Open label trials
monitored by
monitored by assessment
assessmentof
ofclinical
clinicalsymptoms
symptomsand
andserial
serial measurement
measurement of ofthe
the
Answer d is the best description. erythrocyte sedimentation rate and ferritin values.

BM)BMJ111
111 JUNE 20111 VOLUME 342 JUNE 20111 VOLUME 342 1309
1309

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