- Email: [email protected]
Complications of intraosseous infusion
CORRESPONDENCE
t e n t i o n of inorganic acids. Therefore, this study w o u l d need to look at how the a m o u n t of diarrhea, the duration of fasting, and the duration of illness affect thc sensitivity and specificity of the s e r u m bicarbonate as a tool for estim a t i n g m a g n i t u d e of dehydration. Steven R Poole, MD Department of Pediatrics University of Colorado School of Medicine The Children's Hospital of Denver Denver 1. Winters RW: Principle of Pediatric Fluid Therapy. Boston, Little, Brown and Company, 1982, p 96. 2. FinbergL: The management of the critically ill child with dehydration secondary to diarrhea. Pediatrics 1970;45:1029. 3. Lattanzi WL, Siegel NJ: A practical guide to fluid and electrolyte ther-
apy. Curt Probl Pediatr 1986;16:1-43. 4. FleisherGR: Diarrhea, in Fleisher GR, LudwigS (eds): Textbook of Pedi~ attic Emergency Medicine. Baltnnore, Williams and Wilkins, 1983, p 119. 5. RobsonA: Parenteral fluid therapy: Estimation of magnitude and type of deficit (modified from World Health Organization guide), in Behrman RE, VaughVC (eds): Nelson Textbook of Pediatrics, ed 13. Philadelphia,WB Saunders Co, 1982, p 196. 6. Weil WB, Bailie MD: Volume disorders, in Weft WB, Bailie MD: Fluid and Electrolyte Metabolism in Infants and Children: A Unified Approach. New York, Grune and Stratton, 1977, p 9607. 7. Feld LG, Kaskel FJ, SchoenemanMJ: The approach to fluid and electrolyte therapy in pediatrics. Adv Pediatr 1988;35:497-536. 8. Gottlieb RP: Dehydration and fluid therapy. Emerg Med Clin North Am: Symposium on Pediatric Emergencies 1983;1:113. 9. Euchs SM, Jaffe DM: Evaluation of the "tilt test" in children. A n n Emerg Med 1987;16:386-390. 10. LaronZ: Turgor as a quantitative index of dehydration in children. Pediatrics 1957;18:816.
W h e r e A r e t h e F r a c t u r e s and N e e d l e s ? To the Editor: I read w i t h i n t e r e s t "Iatrogenic Bilateral Tibial Fractures After Intraosseous Infusion Attempts in a 3-MonthOld I n f a n t " [October 1989;18:1099-1101[, b u t after thoroughly rereading it, I a m confused as to where the intraosseous needles were placed and where all the fractures are. The abstract states "... healing fractures of both proximal tibias," but the radiographs show two obvious midshaft tibial fractures. Then, in the article, the authors state "Radiographs ... showed ... healing fractures of the midshaft of both tibias." One sentence later they say "Radiographs of the left tibia showed a healing non-displaced fracture of the left proximal tibial shaft." The radiographs were n o t marked as to left or right. In the second paragraph of the article they m e n t i o n proximal tibial and distal femoral insertion sites, but in the fourth paragraph of the discussion they m e n t i o n the "... distal insertion sites . . . " as c o n t r i b u t i n g to the extent of the injuries. If there is any proximal fracture, I am unable to see it. Perhaps an arrow would be useful. I am unable to ascertain from the articles w h e t h e r the needles were indeed placed proximally or distally (both sites were mentioned) or placed midshaft where the fractures are. I a m unable to u n d e r s t a n d from the article if these fractures were caused by questionable technique (large-bore midshaft needle p l a c e m e n t in an infant) or by some as yet unexplainable c o m p l i c a t i o n of a proximally placed needle causing a midshaft fracture. Perhaps you could answer the following questions: Is there a proximal fracture on the
left? Where were the infusion sites? Because of this confusion, I'm not sure if the takehome message is don't put your Jamshidi's in the midshaft (I won't); don't use a 15gauge intraosseous needle in an infant (I won't); to consider p o s t - p l a c e m e n t radiographs to c h e c k for n e e d l e placement (I will); or all the above (yes!). Robert G Crane, MD Sacramento, California In Reply: We apologize for a n y c o n f u s i o n our t e r m i n o l o g y m a y have generated. To clarify: although the tibial insertion sites were described as proximal, they were o b v i o u s l y midshaft. The tibial fractures depicted were at the needle insertion sites as the lateral view of the right tibia shows the anterior soft tissue tract where the needle traversed. The photograph on the left shows an anteroposterior view of both legs w i t h both tibial fractures visible; the photograph on the right shows a lateral view of the right tibia. In conclusion, we t h i n k that the 15-gauge needle used was too large and that the insertion sites were too distal. We also believe that the bones were fractured by the needle itself, not because of any u n u s u a l m a n i p u l a t i o n . Francois R La Fleche, M D David P Milzman, MD Emergency Medicine Residency Program Eastern Virginia Graduate School of Medicine Virginia Beach
C o m p l i c a t i o n s of I n t r a o s s e o u s Infusion To the Editor: La Fleche et al are to be c o m m e n d e d for describing a serious complication of intraosseous infusions. Initial re186/731
ports of n e w t e c h n i q u e s u s u a l l y d e t a i l the ease wit] w h i c h they are performed and their low complication rau
Annals of Emergency Medicine
19:6 June 19,c
FIGURE 1. Tip of Sur-Fast® needle.
i
FIGURE 2. Needle positioned in a lO-month-old infant.
Subsequent studies are u s u a l l y more sobering and docum e n t the n e e d for careful t r a i n i n g and for d i l i g e n c e in identifying c o m p l i c a t i o n s early. A n u m b e r of c o m m e n t s are noteworthy. First, m u l t i p l e p l a c e m e n t a t t e m p t s were m a d e in the s a m e bone. T h e question of w h e t h e r this is appropriate w h e n m o r e than one a t t e m p t p u n c t u r e s the bone has n o t been addressed in the literature. However, it is likely that fluid will extravasate from all p u n c t u r e sites in w h i c h a needle is not present, especially w h e n delivered under pressure. Second1 a t t e m p t e d p l a c e m e n t s were made in an area described as the right proximal tibia. It is clear from the radiographs that the site was the m i d s h a f t rather than the p r o x i m a l end. This site was used on the left leg was well. We have r e c e n t l y developed a n e w intraosseous device (Sur-Fast ®, C o o k Critical Care, Inc, Bloomington, Indiana). During the initial evaluation of the needle on cadavers, we found t h a t the younger the child, the closer the needle needed to be inserted to the p r o x i m a l end of the tibia. T h e authors state that the literature r e c o m m e n d s needle insertion 1 to 2 crn distal to the tibial tuberosity. In fact, in a very s m a l l child, as p r e s e n t e d in t h i s case, t h e n e e d l e m u s t be inserted at the level of the tibial t u b e r o s i t y or very slightly distal to it. As seen in the radiographs and noted in our study, the tibia is sufficiently wide only in the m e t a p h y s e a l area of infants. It is clear from the radiograph that the needle was introduced into an area w h e r e the m e d u l l a r y cavity is very narrow, and the possibility of successful infusion is small. Thus, use of a site 1 to 2 c m distal to the tibial tuberosity as r e c o m m e n d e d in the literature will result in midshaft punctures in infants. One of the major problems w i t h presently available intraosseous i n f u s i o n devices is t h a t significant pressure m u s t be applied axially down the needle in order to insert t h e m into the m a r r o w space. This pressure is perpendicular to the long axis of the bone. W i t h insufficient support of the bone at the insertion site, this can result in fractures, particularly if the needle is inserted near the m i d d l e of the bone. The n e w Sur-Fast ® intraosseous needle significantly reduces the a m o u n t of axial pressure that is applied and virtually e l i m i n a t e s the c o m p l i c a t i o n of extravasation at the insertion site. This needle (Figure 1) has a trifacted c u t t i n g tip similar to that found on a S t e i n m a n pin. This tip is used to bore a p p r o x i m a t e l y 2 to 3 m m into the bone. T h e r e m a i n d e r of the shaft is threaded so that once the initial hole is tapped, far less axial pressure is applied to the needle and thus to the bone. T h e first m o d e l of the Sur-Fast ® needle is 16 gauge. A n 18-gauge needle is in d e v e l o p m e n t for p r e m a t u r e infants and neonates. Figure 2 shows the SUr-Fast ® needle properly positioned in the bone m a r r o w f a 10-month-old infant w h o presented to the e m e r g e n c y e p a r t m e n t in septic s h o c k and s i c k l e cell crisis. N o t e at the i n s e r t i o n is at the level of the tibial t u b e r o s i t y ~9:6 June 1990
~
/ i! ¸¸ /
x
iiiii!iiiiiiiiiiiiiiiiii!
and t h a t there is a d e q u a t e d i s t a n c e b e t w e e n the needle and the epiphyseal plate. A n u m b e r of o t h e r p o i n t s are w o r t h m e n t i o n i n g . A l l c h i l d r e n in w h o m i n t r a o s s e o u s i n s e r t i o n has b e e n att e m p t e d or performed should have follow-up radiographs of the insertion site. Also, m o s t courses teaching intraosseous infusion use chicken d r u m s t i c k s as a model. We find this m o d e l to be unsuitable. The "feel" of this very brittle calcified bone is quite different than that felt on insertion in a small infant or child. We find swine ribs to be a good m o d e l for practicing insertion of the Sur-Fast ® needle. Lastly, the case report reveals that intraosseous infusion was not a t t e m p t e d until after a t t e m p t s at peripheral IV p l a c e m e n t s had failed. We c o n t i n u e to stress the need for i m m e d i a t e vascular access and suggest that intraosseous infusion be considered very early in the resuscitation as a m e t h o d equally as appropriate as peripheral IV insertion. Intraosseous infusion is an i m p o r t a n t tool in the armam e n t a r i u m of the p h y s i c i a n caring for infants and small children. However, it requires adequate practice and skill to keep the c o m p l i c a t i o n rate acceptably low. We are confident that this technique will continue to flourish and that its use will be expanded to older children and young adults.
Richard J Melker, MD, PhD Gary Miller, PhD Peter Gearen, MD Lisa Molliter, ARNP Departments of Surgery (Emergency Medicine), Orthopaedics, and Nursing University of Florida College of Medicine Gainesville
Annals of Emergency Medicine
732/187
t e n t i o n of inorganic acids. Therefore, this study w o u l d need to look at how the a m o u n t of diarrhea, the duration of fasting, and the duration of illness affect thc sensitivity and specificity of the s e r u m bicarbonate as a tool for estim a t i n g m a g n i t u d e of dehydration. Steven R Poole, MD Department of Pediatrics University of Colorado School of Medicine The Children's Hospital of Denver Denver 1. Winters RW: Principle of Pediatric Fluid Therapy. Boston, Little, Brown and Company, 1982, p 96. 2. FinbergL: The management of the critically ill child with dehydration secondary to diarrhea. Pediatrics 1970;45:1029. 3. Lattanzi WL, Siegel NJ: A practical guide to fluid and electrolyte ther-
apy. Curt Probl Pediatr 1986;16:1-43. 4. FleisherGR: Diarrhea, in Fleisher GR, LudwigS (eds): Textbook of Pedi~ attic Emergency Medicine. Baltnnore, Williams and Wilkins, 1983, p 119. 5. RobsonA: Parenteral fluid therapy: Estimation of magnitude and type of deficit (modified from World Health Organization guide), in Behrman RE, VaughVC (eds): Nelson Textbook of Pediatrics, ed 13. Philadelphia,WB Saunders Co, 1982, p 196. 6. Weil WB, Bailie MD: Volume disorders, in Weft WB, Bailie MD: Fluid and Electrolyte Metabolism in Infants and Children: A Unified Approach. New York, Grune and Stratton, 1977, p 9607. 7. Feld LG, Kaskel FJ, SchoenemanMJ: The approach to fluid and electrolyte therapy in pediatrics. Adv Pediatr 1988;35:497-536. 8. Gottlieb RP: Dehydration and fluid therapy. Emerg Med Clin North Am: Symposium on Pediatric Emergencies 1983;1:113. 9. Euchs SM, Jaffe DM: Evaluation of the "tilt test" in children. A n n Emerg Med 1987;16:386-390. 10. LaronZ: Turgor as a quantitative index of dehydration in children. Pediatrics 1957;18:816.
W h e r e A r e t h e F r a c t u r e s and N e e d l e s ? To the Editor: I read w i t h i n t e r e s t "Iatrogenic Bilateral Tibial Fractures After Intraosseous Infusion Attempts in a 3-MonthOld I n f a n t " [October 1989;18:1099-1101[, b u t after thoroughly rereading it, I a m confused as to where the intraosseous needles were placed and where all the fractures are. The abstract states "... healing fractures of both proximal tibias," but the radiographs show two obvious midshaft tibial fractures. Then, in the article, the authors state "Radiographs ... showed ... healing fractures of the midshaft of both tibias." One sentence later they say "Radiographs of the left tibia showed a healing non-displaced fracture of the left proximal tibial shaft." The radiographs were n o t marked as to left or right. In the second paragraph of the article they m e n t i o n proximal tibial and distal femoral insertion sites, but in the fourth paragraph of the discussion they m e n t i o n the "... distal insertion sites . . . " as c o n t r i b u t i n g to the extent of the injuries. If there is any proximal fracture, I am unable to see it. Perhaps an arrow would be useful. I am unable to ascertain from the articles w h e t h e r the needles were indeed placed proximally or distally (both sites were mentioned) or placed midshaft where the fractures are. I a m unable to u n d e r s t a n d from the article if these fractures were caused by questionable technique (large-bore midshaft needle p l a c e m e n t in an infant) or by some as yet unexplainable c o m p l i c a t i o n of a proximally placed needle causing a midshaft fracture. Perhaps you could answer the following questions: Is there a proximal fracture on the
left? Where were the infusion sites? Because of this confusion, I'm not sure if the takehome message is don't put your Jamshidi's in the midshaft (I won't); don't use a 15gauge intraosseous needle in an infant (I won't); to consider p o s t - p l a c e m e n t radiographs to c h e c k for n e e d l e placement (I will); or all the above (yes!). Robert G Crane, MD Sacramento, California In Reply: We apologize for a n y c o n f u s i o n our t e r m i n o l o g y m a y have generated. To clarify: although the tibial insertion sites were described as proximal, they were o b v i o u s l y midshaft. The tibial fractures depicted were at the needle insertion sites as the lateral view of the right tibia shows the anterior soft tissue tract where the needle traversed. The photograph on the left shows an anteroposterior view of both legs w i t h both tibial fractures visible; the photograph on the right shows a lateral view of the right tibia. In conclusion, we t h i n k that the 15-gauge needle used was too large and that the insertion sites were too distal. We also believe that the bones were fractured by the needle itself, not because of any u n u s u a l m a n i p u l a t i o n . Francois R La Fleche, M D David P Milzman, MD Emergency Medicine Residency Program Eastern Virginia Graduate School of Medicine Virginia Beach
C o m p l i c a t i o n s of I n t r a o s s e o u s Infusion To the Editor: La Fleche et al are to be c o m m e n d e d for describing a serious complication of intraosseous infusions. Initial re186/731
ports of n e w t e c h n i q u e s u s u a l l y d e t a i l the ease wit] w h i c h they are performed and their low complication rau
Annals of Emergency Medicine
19:6 June 19,c
FIGURE 1. Tip of Sur-Fast® needle.
i
FIGURE 2. Needle positioned in a lO-month-old infant.
Subsequent studies are u s u a l l y more sobering and docum e n t the n e e d for careful t r a i n i n g and for d i l i g e n c e in identifying c o m p l i c a t i o n s early. A n u m b e r of c o m m e n t s are noteworthy. First, m u l t i p l e p l a c e m e n t a t t e m p t s were m a d e in the s a m e bone. T h e question of w h e t h e r this is appropriate w h e n m o r e than one a t t e m p t p u n c t u r e s the bone has n o t been addressed in the literature. However, it is likely that fluid will extravasate from all p u n c t u r e sites in w h i c h a needle is not present, especially w h e n delivered under pressure. Second1 a t t e m p t e d p l a c e m e n t s were made in an area described as the right proximal tibia. It is clear from the radiographs that the site was the m i d s h a f t rather than the p r o x i m a l end. This site was used on the left leg was well. We have r e c e n t l y developed a n e w intraosseous device (Sur-Fast ®, C o o k Critical Care, Inc, Bloomington, Indiana). During the initial evaluation of the needle on cadavers, we found t h a t the younger the child, the closer the needle needed to be inserted to the p r o x i m a l end of the tibia. T h e authors state that the literature r e c o m m e n d s needle insertion 1 to 2 crn distal to the tibial tuberosity. In fact, in a very s m a l l child, as p r e s e n t e d in t h i s case, t h e n e e d l e m u s t be inserted at the level of the tibial t u b e r o s i t y or very slightly distal to it. As seen in the radiographs and noted in our study, the tibia is sufficiently wide only in the m e t a p h y s e a l area of infants. It is clear from the radiograph that the needle was introduced into an area w h e r e the m e d u l l a r y cavity is very narrow, and the possibility of successful infusion is small. Thus, use of a site 1 to 2 c m distal to the tibial tuberosity as r e c o m m e n d e d in the literature will result in midshaft punctures in infants. One of the major problems w i t h presently available intraosseous i n f u s i o n devices is t h a t significant pressure m u s t be applied axially down the needle in order to insert t h e m into the m a r r o w space. This pressure is perpendicular to the long axis of the bone. W i t h insufficient support of the bone at the insertion site, this can result in fractures, particularly if the needle is inserted near the m i d d l e of the bone. The n e w Sur-Fast ® intraosseous needle significantly reduces the a m o u n t of axial pressure that is applied and virtually e l i m i n a t e s the c o m p l i c a t i o n of extravasation at the insertion site. This needle (Figure 1) has a trifacted c u t t i n g tip similar to that found on a S t e i n m a n pin. This tip is used to bore a p p r o x i m a t e l y 2 to 3 m m into the bone. T h e r e m a i n d e r of the shaft is threaded so that once the initial hole is tapped, far less axial pressure is applied to the needle and thus to the bone. T h e first m o d e l of the Sur-Fast ® needle is 16 gauge. A n 18-gauge needle is in d e v e l o p m e n t for p r e m a t u r e infants and neonates. Figure 2 shows the SUr-Fast ® needle properly positioned in the bone m a r r o w f a 10-month-old infant w h o presented to the e m e r g e n c y e p a r t m e n t in septic s h o c k and s i c k l e cell crisis. N o t e at the i n s e r t i o n is at the level of the tibial t u b e r o s i t y ~9:6 June 1990
~
/ i! ¸¸ /
x
iiiii!iiiiiiiiiiiiiiiiii!
and t h a t there is a d e q u a t e d i s t a n c e b e t w e e n the needle and the epiphyseal plate. A n u m b e r of o t h e r p o i n t s are w o r t h m e n t i o n i n g . A l l c h i l d r e n in w h o m i n t r a o s s e o u s i n s e r t i o n has b e e n att e m p t e d or performed should have follow-up radiographs of the insertion site. Also, m o s t courses teaching intraosseous infusion use chicken d r u m s t i c k s as a model. We find this m o d e l to be unsuitable. The "feel" of this very brittle calcified bone is quite different than that felt on insertion in a small infant or child. We find swine ribs to be a good m o d e l for practicing insertion of the Sur-Fast ® needle. Lastly, the case report reveals that intraosseous infusion was not a t t e m p t e d until after a t t e m p t s at peripheral IV p l a c e m e n t s had failed. We c o n t i n u e to stress the need for i m m e d i a t e vascular access and suggest that intraosseous infusion be considered very early in the resuscitation as a m e t h o d equally as appropriate as peripheral IV insertion. Intraosseous infusion is an i m p o r t a n t tool in the armam e n t a r i u m of the p h y s i c i a n caring for infants and small children. However, it requires adequate practice and skill to keep the c o m p l i c a t i o n rate acceptably low. We are confident that this technique will continue to flourish and that its use will be expanded to older children and young adults.
Richard J Melker, MD, PhD Gary Miller, PhD Peter Gearen, MD Lisa Molliter, ARNP Departments of Surgery (Emergency Medicine), Orthopaedics, and Nursing University of Florida College of Medicine Gainesville
Annals of Emergency Medicine
732/187