Intended for healthcare professionals

Practice Lesson of the week

Amputation and intraosseous access in infants

BMJ 2011; 342 doi: (Published 27 May 2011) Cite this as: BMJ 2011;342:d2778
  1. Colm C Taylor, senior clinical fellow ,
  2. N M P Clarke, consultant orthopaedic surgeon
  1. 1Southampton General Hospital, Tremona Road SO16 6YD, UK
  1. Correspondence to: N M P Clarke ortho{at}
  • Accepted 15 March 2011

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 venous access fail.1 The proximal tibia is the preferred site for intraosseous needle insertion, with an accessible subcutaneous cortex. Manual insertion of the intraosseous needle can be supplemented with approved impact driven and power driven needle systems.2

Intraosseous access has low failure and complication rates,3 but compartment syndrome has been reported in association with this procedure,4 and preventive measures have been recommended.5 Three cases of amputation have been reported, preceded by clinical features of compartment syndrome within a few hours of admission.6

We describe two cases of leg amputation after intraosseous infusion to emphasise the risk of limb ischaemia during paediatric resuscitation by this route.

Case reports

Case 1

A 5 month old girl was resuscitated at a local hospital for pulseless cardiac arrest caused by unrecognised congenital diaphragmatic hernia. Emergent bilateral proximal tibial intraosseous access was achieved with a power driven system. Resuscitation included 1:10 000 adrenaline solution, 200 mL normal saline, 15 mmol sodium bicarbonate, 10 µg/kg dopamine infusion, and whole …

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