Intraosseous Infusion: Elective Use in Pediatric Anesthesia Frank C. Stewart,
MD,
and Zeev N. Kain,
MD
Department of Anesthesia, Children’s Hospital, and Harvard Medical School, Boston, Massachusetts
T
he intraosseous (10) route for parenteral access is increasingly being used for resuscitation of infants and children (1). Only one case has been documented in the recent anesthesia literature (2) representing a last resort during cardiopulmonary resuscitation. We report elective use of I 0 parenteral infusion for induction and maintenance of anesthesia in an infant with no readily available intravenous (IV) access.
Case Report A 3-mo-old male child was scheduled for revision of a ventriculoperitoneal (VP) shunt. The shunt had been inserted 2 wk earlier but had apparently become disconnected at the reservoir, because cerebrospinal fluid was collecting beneath the scalp, adjacent to the incision. The patient was a low-birth-weight term infant born at an outlying hospital by normal sinus vaginal delivery after an unremarkable gestational history. Cyanosis and respiratory distress dictated early endotracheal intubation and mechanical ventilation. Echocardiogram and cardiac catheterization revealed multiple cardiac anomalies, including a single left ventricle. Pulmonary artery banding was performed after administration of furosemide and digoxin failed to control progressive cardiac failure. After transfer to our hospital at 18 days of age, he underwent patent ductus arteriosus ligation and removal of the pulmonary band. His prolonged intensive care unit course was complicated by chronic bilateral upper lobe collapse requiring intensive chest physiotherapy, frequent nebulization, and, eventually, bronchoscopy under general anesthesia. Seizure activity prompted a magnetic resonance imaging scan that revealed large ventricles and cerebral atrophy. The first attempt to place a VP shunt was canceled after several experienced anesthesiologists were unable to establish venous access. The Accepted for publication June 1, 1992. Address correspondence to Dr. Stewart, Department of Anesthesia, Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115-5737.
626
Anesth Analg 1992;75:626-9
shunt operation was performed the following day after a brachial venous catheter was placed by cutdown, which was the third site attempted that day. Two weeks later, the patient was scheduled for VP shunt revision after radiographs revealed a disconnection at the cranial reservoir. Because cerebrospinal fluid was extravasating subcutaneously and the patient had a palpably soft fontanelle, he was not thought to have increased intracranial pressure. He received medications and maintenance fluids by nasogastric tube until 2 h before his scheduled operating room time. A pediatric bone marrow needle was obtained from the emergency department, and a plan was discussed with the surgeons to pursue I 0 line placement if reasonable attempts at peripheral line placement were unsuccessful. Intraosseous access, including possible complications, was then discussed in detail with the patient’s parents. In the operating room, peripheral IV placement was attempted in all four extremities for 20 min, at which time the decision to use the I 0 route was made. The needle was placed in the proximal tibia under sterile conditions, requiring 5 min for completion. An intramuscular injection of ketamine and glycopyrrolate had been given before bone marrow puncture, although I 0 needle insertion can be performed in an awake patient using local anesthetic infiltration. Once access was established, lactated Rnger’s solution (10 mL/kg) was administered, followed by pancuronium (0.1 mg/kg) and 5 mL of saline solution flush. Neuromuscular blockade was considered adequate at 180 s by loss-of-twitch response. After intubation, the case proceeded uneventfully, with maintenance fluids and antibiotics delivered by I 0 route. Reversal of neuromuscular blockade was accomplished through the bone marrow needle, and the trachea was extubated in the operating room. The I 0 line was maintained in the recovery room for continued delivery of fluids and an additional dose of antibiotics. The line was discontinued soon after the patient’s arrival at the ward. No complications of I 0 infusion were seen. The child’s pulmonary status, although continuing to require vigorous chest physiotherapy and frequent 01992 by the International Anesthesia Research Society oon3-~999~9z~~~.nn
ANESTH ANALC 1992;75:62&9
nebulization, was unchanged from what it had been preoperatively. The patient was discharged from the hospital 11 days after the VP shunt revision.
Discussion This case represents an example of an increasing number of infants and children who undergo multiple surgical procedures or long intensive care unit courses and present with impossible IV access. Our patient had occupied an intensive care unit bed for 10 of his 12 wk of life. Central line history included bilateral catheterization of internal and external jugular veins, subclavian veins, and femoral veins. His primary physicians strongly advised against further attempts at percutaneous central venous access because of his complex cardiac anatomy and a history of failure to cannulate the jugular or subclavian vessels. The surgical staff had attempted femoral vein catheterization multiple times on both sides the evening before surgery without success. Multiple cutdowns had previously been carried out on all four extremities, including the femoral veins. A brachial cutdown had been successful 2 wk before this operation but was the third site and required 1.5 h to complete. The number of peripheral venipunctures could conservatively be estimated to number 100-200 over the course of his hospitalization. We believed that I 0 infusion was the better alternative to a difficult and prolonged venous cutdown in a patient whose polycythemia (hematocrit 56%) would place him at considerable risk if allowed to become hypovolemic. Intraosseous infusion for the purpose of fluid resuscitation was first described by Doan (3) and Drinker et al. (4) in 1922. Successive reports from the 1930s and 1940s detailed indications, methods, and complications (5-11). The primary indication was for simple fluid resuscitation in infants and young children in whom IV access was difficult. The current use of I 0 infusions is only a few years old. Its resurgence in popularity filled a clinical need for rapid access to the intravascular system in neonates who would die without immediate infusions of fluid or medications, or both. This rebirth and subsequent reevaluation has been primarily documented in the emergency medicine literature (12-23). Elective use of I 0 infusion for induction and maintenance of anesthesia has not been previously reported. Current uses include access during cardiac arrest, shock, extensive burns, and major trauma. Further indications include administration of diazepam and phenytoin for seizure control, continuous administration of dopamine and dobutamine for inotropic support, antibiotics for presumed sepsis, insulin for diabetic ketoacidosis, and administration of a variety of other drugs (16,18,2+28). Use of the I 0
CASE REPORTS
627
route has been anecdotally reported for airway management (15,16). Intraosseous succinylcholine can be utilized for airway control in patients with status epilepticus, combative head-injured patients, and pediatric burn patients, and thiopental administration has also been described (15,24). Clinical time to onset of action after I 0 infusion of several drugs, notably succinylcholine, atropine, and diazepam, has been reported previously (15,16,24). Animal studies have analyzed plasma levels for succinylcholine, atropine, diazepam, and phenobarbital comparing IV, 10, intramuscular, and endotracheal routes (12,17,18). Moore et al. (17) recorded the time to respiratory arrest and loss of forefoot twitch after IV, 10, or endotracheal administration of succinylcholine (1.0 mg/kg) in sheep. Comparing IV with I 0 infusion, they found that respiratory arrest was delayed by approximately 27 s in the I 0 group (30.8 & 7.3 [IV]; 57.5 10.3 [IO]), whereas time to 100% loss of forefoot twitch was slower in the I 0 group by only 7.5 s (93.3 2 34.0 [IV]; 100.8 24.2 [IO]). These studies compared favorably with our clinical finding of virtually no delay in relaxation for pancuronium. The medullary cavity in long bones is composed of a network of venous sinusoids that drain into a central venous canal. Blood exits the venous canal via nutrient or emissary veins into the systemic venous circulation. Children lo0 mL/h (29). The technique has been reported to be used in the femur, tibia, iliac crest, and sternum. Preferred insertion sites in children include the proximal and distal tibia and the distal femur (1,2,14,23). The proximal tibia is generally agreed to be the optimal site because it has a broad, flat surface covered by a thin layer of skin. However, at ages >5-6 yr, the proximal tibia becomes much thicker and harder to penetrate, making the distal tibia preferable. When using the proximal tibia, the tibial tuberosity is palpated and a point is selected in the midline on the anteromedial, flat surface, 2-3 cm below the tibial tuberosity. The needle is inserted at an angle of 60"-90" away from the epiphyseal plate to avoid any damage. The bevel should point away from the joint space, and a rotary motion is applied, similar to that used for a bone marrow biopsy. Aspiration of bone marrow confirms proper placement. Use of the I 0 route for induction and maintenance
*
*
628
ANESTH ANALG 1992;75:62&9
CASE REPORTS
of anesthesia was suggested in the 1940s-1950s (10); however, this method should not be used routinely in cases of difficult pediatric IV access before considering a number of potential problems. Of the complications associated with I 0 infusion, extravasation of fluid around the puncture site is the most common. If the extravasated fluid is crystalloid, this presents no problem; however, if it is sodium bicarbonate or some other alkaline agent, local tissue damage may occur. Of more concern is the risk of osteomyelitis and cellulitis. Rosetti et al. (30) reviewed the literature from 1942 to 1977 and found only 27 reported cases of osteomyelitis in >4000 I 0 infusions. This rate of 0.670 compares favorably with a 3.7% incidence of local infection associated with the use of venous cannulas (31). In addition, the reports of osteomyelitis are from 40 yr ago, before the use of broad-spectrum antibiotics, and involved I 0 infusions of long duration and of hypertonic solutions. There have been no cases of osteomyelitis reported in the recent literature subsequent to the use of I 0 infusions. Many physicians are concerned about possible damage to the epiphyseal plate and bone marrow elements. However, there has never been a reported case of damage to the epiphyseal plate, and no lasting negative eaects have been identified in multiple clinical and experimental trials (1,14). Potential injury to the growth plate can be avoided by taking care to palpate bony landmarks and to place the needle away from the joint space. Fat or bone marrow emboli have been regarded as potential complications, but no cases have been documented. Heinild et al. (5), using postmortem examinations of patients, reported no evidence of fat emboli in approximately 1000 pediatric infusions. More recently, Orlowski et al. (26) found a high incidence of fat and bone marrow emboli in the lungs of a canine model subsequent to I 0 infusion. Ventilation-perfusion relationships, assessed by analyzing arterial blood gases in these animals, failed to reveal any significant change, even though the incidence of bone marrow or fat emboli in pulmonary blood vessels was found to be as high as 4.48 emboli/mm2. The same authors also reported anecdotally that bone marrow emboli were found in the lungs of two infants who died after major resuscitation episodes, including I 0 infusions. Whether this data can be applied to humans not undergoing cardiopulmonary resuscitation and not subject to the forces of external cardiac massage is unknown. However, the authors chose to recommend that this technique not be used in patients with intracardiac right-to-left shunts, referring to the theoretically increased morbidity associated with systemic emboli of any type. A recent review article (1) mentioned the possibility of fat embolism but dismissed its importance, pointing out
that the marrow of children is relatively fat free. This article did not include children with intracardiac shunts in its list of absolute contraindications (osteogenesis imperfecta, osteopetrosis, and ipsilateral fractured extremity). For relatively short procedures, I 0 infusion should be considered by anesthesiologists for cases of extreme difficulty in obtaining IV access in children
MD,
and Zeev N. Kain,
MD
Department of Anesthesia, Children’s Hospital, and Harvard Medical School, Boston, Massachusetts
T
he intraosseous (10) route for parenteral access is increasingly being used for resuscitation of infants and children (1). Only one case has been documented in the recent anesthesia literature (2) representing a last resort during cardiopulmonary resuscitation. We report elective use of I 0 parenteral infusion for induction and maintenance of anesthesia in an infant with no readily available intravenous (IV) access.
Case Report A 3-mo-old male child was scheduled for revision of a ventriculoperitoneal (VP) shunt. The shunt had been inserted 2 wk earlier but had apparently become disconnected at the reservoir, because cerebrospinal fluid was collecting beneath the scalp, adjacent to the incision. The patient was a low-birth-weight term infant born at an outlying hospital by normal sinus vaginal delivery after an unremarkable gestational history. Cyanosis and respiratory distress dictated early endotracheal intubation and mechanical ventilation. Echocardiogram and cardiac catheterization revealed multiple cardiac anomalies, including a single left ventricle. Pulmonary artery banding was performed after administration of furosemide and digoxin failed to control progressive cardiac failure. After transfer to our hospital at 18 days of age, he underwent patent ductus arteriosus ligation and removal of the pulmonary band. His prolonged intensive care unit course was complicated by chronic bilateral upper lobe collapse requiring intensive chest physiotherapy, frequent nebulization, and, eventually, bronchoscopy under general anesthesia. Seizure activity prompted a magnetic resonance imaging scan that revealed large ventricles and cerebral atrophy. The first attempt to place a VP shunt was canceled after several experienced anesthesiologists were unable to establish venous access. The Accepted for publication June 1, 1992. Address correspondence to Dr. Stewart, Department of Anesthesia, Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115-5737.
626
Anesth Analg 1992;75:626-9
shunt operation was performed the following day after a brachial venous catheter was placed by cutdown, which was the third site attempted that day. Two weeks later, the patient was scheduled for VP shunt revision after radiographs revealed a disconnection at the cranial reservoir. Because cerebrospinal fluid was extravasating subcutaneously and the patient had a palpably soft fontanelle, he was not thought to have increased intracranial pressure. He received medications and maintenance fluids by nasogastric tube until 2 h before his scheduled operating room time. A pediatric bone marrow needle was obtained from the emergency department, and a plan was discussed with the surgeons to pursue I 0 line placement if reasonable attempts at peripheral line placement were unsuccessful. Intraosseous access, including possible complications, was then discussed in detail with the patient’s parents. In the operating room, peripheral IV placement was attempted in all four extremities for 20 min, at which time the decision to use the I 0 route was made. The needle was placed in the proximal tibia under sterile conditions, requiring 5 min for completion. An intramuscular injection of ketamine and glycopyrrolate had been given before bone marrow puncture, although I 0 needle insertion can be performed in an awake patient using local anesthetic infiltration. Once access was established, lactated Rnger’s solution (10 mL/kg) was administered, followed by pancuronium (0.1 mg/kg) and 5 mL of saline solution flush. Neuromuscular blockade was considered adequate at 180 s by loss-of-twitch response. After intubation, the case proceeded uneventfully, with maintenance fluids and antibiotics delivered by I 0 route. Reversal of neuromuscular blockade was accomplished through the bone marrow needle, and the trachea was extubated in the operating room. The I 0 line was maintained in the recovery room for continued delivery of fluids and an additional dose of antibiotics. The line was discontinued soon after the patient’s arrival at the ward. No complications of I 0 infusion were seen. The child’s pulmonary status, although continuing to require vigorous chest physiotherapy and frequent 01992 by the International Anesthesia Research Society oon3-~999~9z~~~.nn
ANESTH ANALC 1992;75:62&9
nebulization, was unchanged from what it had been preoperatively. The patient was discharged from the hospital 11 days after the VP shunt revision.
Discussion This case represents an example of an increasing number of infants and children who undergo multiple surgical procedures or long intensive care unit courses and present with impossible IV access. Our patient had occupied an intensive care unit bed for 10 of his 12 wk of life. Central line history included bilateral catheterization of internal and external jugular veins, subclavian veins, and femoral veins. His primary physicians strongly advised against further attempts at percutaneous central venous access because of his complex cardiac anatomy and a history of failure to cannulate the jugular or subclavian vessels. The surgical staff had attempted femoral vein catheterization multiple times on both sides the evening before surgery without success. Multiple cutdowns had previously been carried out on all four extremities, including the femoral veins. A brachial cutdown had been successful 2 wk before this operation but was the third site and required 1.5 h to complete. The number of peripheral venipunctures could conservatively be estimated to number 100-200 over the course of his hospitalization. We believed that I 0 infusion was the better alternative to a difficult and prolonged venous cutdown in a patient whose polycythemia (hematocrit 56%) would place him at considerable risk if allowed to become hypovolemic. Intraosseous infusion for the purpose of fluid resuscitation was first described by Doan (3) and Drinker et al. (4) in 1922. Successive reports from the 1930s and 1940s detailed indications, methods, and complications (5-11). The primary indication was for simple fluid resuscitation in infants and young children in whom IV access was difficult. The current use of I 0 infusions is only a few years old. Its resurgence in popularity filled a clinical need for rapid access to the intravascular system in neonates who would die without immediate infusions of fluid or medications, or both. This rebirth and subsequent reevaluation has been primarily documented in the emergency medicine literature (12-23). Elective use of I 0 infusion for induction and maintenance of anesthesia has not been previously reported. Current uses include access during cardiac arrest, shock, extensive burns, and major trauma. Further indications include administration of diazepam and phenytoin for seizure control, continuous administration of dopamine and dobutamine for inotropic support, antibiotics for presumed sepsis, insulin for diabetic ketoacidosis, and administration of a variety of other drugs (16,18,2+28). Use of the I 0
CASE REPORTS
627
route has been anecdotally reported for airway management (15,16). Intraosseous succinylcholine can be utilized for airway control in patients with status epilepticus, combative head-injured patients, and pediatric burn patients, and thiopental administration has also been described (15,24). Clinical time to onset of action after I 0 infusion of several drugs, notably succinylcholine, atropine, and diazepam, has been reported previously (15,16,24). Animal studies have analyzed plasma levels for succinylcholine, atropine, diazepam, and phenobarbital comparing IV, 10, intramuscular, and endotracheal routes (12,17,18). Moore et al. (17) recorded the time to respiratory arrest and loss of forefoot twitch after IV, 10, or endotracheal administration of succinylcholine (1.0 mg/kg) in sheep. Comparing IV with I 0 infusion, they found that respiratory arrest was delayed by approximately 27 s in the I 0 group (30.8 & 7.3 [IV]; 57.5 10.3 [IO]), whereas time to 100% loss of forefoot twitch was slower in the I 0 group by only 7.5 s (93.3 2 34.0 [IV]; 100.8 24.2 [IO]). These studies compared favorably with our clinical finding of virtually no delay in relaxation for pancuronium. The medullary cavity in long bones is composed of a network of venous sinusoids that drain into a central venous canal. Blood exits the venous canal via nutrient or emissary veins into the systemic venous circulation. Children lo0 mL/h (29). The technique has been reported to be used in the femur, tibia, iliac crest, and sternum. Preferred insertion sites in children include the proximal and distal tibia and the distal femur (1,2,14,23). The proximal tibia is generally agreed to be the optimal site because it has a broad, flat surface covered by a thin layer of skin. However, at ages >5-6 yr, the proximal tibia becomes much thicker and harder to penetrate, making the distal tibia preferable. When using the proximal tibia, the tibial tuberosity is palpated and a point is selected in the midline on the anteromedial, flat surface, 2-3 cm below the tibial tuberosity. The needle is inserted at an angle of 60"-90" away from the epiphyseal plate to avoid any damage. The bevel should point away from the joint space, and a rotary motion is applied, similar to that used for a bone marrow biopsy. Aspiration of bone marrow confirms proper placement. Use of the I 0 route for induction and maintenance
*
*
628
ANESTH ANALG 1992;75:62&9
CASE REPORTS
of anesthesia was suggested in the 1940s-1950s (10); however, this method should not be used routinely in cases of difficult pediatric IV access before considering a number of potential problems. Of the complications associated with I 0 infusion, extravasation of fluid around the puncture site is the most common. If the extravasated fluid is crystalloid, this presents no problem; however, if it is sodium bicarbonate or some other alkaline agent, local tissue damage may occur. Of more concern is the risk of osteomyelitis and cellulitis. Rosetti et al. (30) reviewed the literature from 1942 to 1977 and found only 27 reported cases of osteomyelitis in >4000 I 0 infusions. This rate of 0.670 compares favorably with a 3.7% incidence of local infection associated with the use of venous cannulas (31). In addition, the reports of osteomyelitis are from 40 yr ago, before the use of broad-spectrum antibiotics, and involved I 0 infusions of long duration and of hypertonic solutions. There have been no cases of osteomyelitis reported in the recent literature subsequent to the use of I 0 infusions. Many physicians are concerned about possible damage to the epiphyseal plate and bone marrow elements. However, there has never been a reported case of damage to the epiphyseal plate, and no lasting negative eaects have been identified in multiple clinical and experimental trials (1,14). Potential injury to the growth plate can be avoided by taking care to palpate bony landmarks and to place the needle away from the joint space. Fat or bone marrow emboli have been regarded as potential complications, but no cases have been documented. Heinild et al. (5), using postmortem examinations of patients, reported no evidence of fat emboli in approximately 1000 pediatric infusions. More recently, Orlowski et al. (26) found a high incidence of fat and bone marrow emboli in the lungs of a canine model subsequent to I 0 infusion. Ventilation-perfusion relationships, assessed by analyzing arterial blood gases in these animals, failed to reveal any significant change, even though the incidence of bone marrow or fat emboli in pulmonary blood vessels was found to be as high as 4.48 emboli/mm2. The same authors also reported anecdotally that bone marrow emboli were found in the lungs of two infants who died after major resuscitation episodes, including I 0 infusions. Whether this data can be applied to humans not undergoing cardiopulmonary resuscitation and not subject to the forces of external cardiac massage is unknown. However, the authors chose to recommend that this technique not be used in patients with intracardiac right-to-left shunts, referring to the theoretically increased morbidity associated with systemic emboli of any type. A recent review article (1) mentioned the possibility of fat embolism but dismissed its importance, pointing out
that the marrow of children is relatively fat free. This article did not include children with intracardiac shunts in its list of absolute contraindications (osteogenesis imperfecta, osteopetrosis, and ipsilateral fractured extremity). For relatively short procedures, I 0 infusion should be considered by anesthesiologists for cases of extreme difficulty in obtaining IV access in children
