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Intraosseous Access Gone Awry FREE TO VIEW

Yonatan Greenstein; Astha Chichra; Seth Koenig; Paul Mayo; Managala Narasimhan
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Hofstra North Shore - LIJ, New York, NY

Chest. 2014;146(4_MeetingAbstracts):263A. doi:10.1378/chest.1988653
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SESSION TITLE: Critical Care Case Report Posters III

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: The 2010 guidelines for advanced cardiac life support recommend intraosseous (IO) access if intravenous (IV) access is not readily attainable.1 We report a case of vasopressor extravasation and threatened limb perfusion related to IO access use and our management of the complication.

CASE PRESENTATION: A 42 year old man was hospitalized for colonic pseudo-obstruction when he became unarousable and hypotensive with a systolic blood pressure (BP) of 40 mmHg. A 22-gauge peripheral IV was in place and several attempts to establish another IV were unsuccessful. An IO needle (EZ-IO, 15 gauge 25mm, Vidacare) was inserted into the proximal tibia of the right lower extremity (RLE) without difficulty. Bone marrow was aspirated and the line flushed easily. The needle was secured (EZ-Stabilizer, Vidacare). A dopamine drip was started via the IO needle and norepinephrine was subsequently added. His BP stabilized and he was transferred to the medical intensive care unit (MICU). In the MICU a central venous line (CVL) was placed and the vasopressors were switched to it. The RLE was mottled, cold, and a dorsalis pedis (DP) and posterior tibialis pulse were absent by Doppler. The femoral pulse was palpable. There was no swelling or tenseness in the RLE. On ultrasound, flow was limited past the branch point of the superficial and deep femoral artery. We hypothesized that the IO needle migrated and that vasopressors extravasated into the soft tissues causing vasoconstriction of the superficial and deep femoral arteries. We placed nitroglycerin 2% ointment on the skin of the RLE, injected phentolamine 5mg into the IO needle, and removed the IO needle. Verapamil 2.5mg and nitroglycerin 0.2mg were injected into the right common femoral artery. Within a few hours the mottled appearance dissipated and a palpable DP pulse was present with Doppler flow throughout.

DISCUSSION: Complications with IO access have been reported in the pediatric literature2-3; little is reported in adults. Our treatment included cessation of IO infusion and therapy to reverse potential actions of the extravasated vasopressors via topical vasodilatory therapy, IO alpha-1 blockage, and intra-arterial vasodilation to relieve vasoconstriction.

CONCLUSIONS: Intraosseous access is a valuable tool, however, the rate and type of complications associated with its use is likely underreported. Research is needed to guide management of associated complications.

Reference #1: Circulation 2010;122:S729-67

Reference #2: J Bone Joint Surg Am 1993;75(3):430-3

Reference #3: Ann Saudi Med 2008;28(6):456-7

DISCLOSURE: The following authors have nothing to disclose: Yonatan Greenstein, Astha Chichra, Seth Koenig, Paul Mayo, Managala Narasimhan

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