miércoles, 27 de agosto de 2014

AHRQ WebM&M: Morbidity and Mortality Rounds on the Web: Benefits vs. Risks of Intraosseous Vascular Access


AHRQ WebM&M: Morbidity and Mortality Rounds on the Web

AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care

Benefits vs. Risks of Intraosseous Vascular Access
Commentary by Raymond L. Fowler, MD, and Melanie J. Lippmann, MD

The Case

A 72-year-old woman with a history of asthma, congestive heart failure, and medication noncompliance presented to the emergency department with 2 weeks of lower extremity edema, fatigue, and progressively worsening dyspnea. She reported shortness of breath at rest and with exertion, as well as a dry cough. On initial examination, she was wheezing and had notable right lower extremity erythema and bilateral lower extremity pitting edema greater on the right side with weeping from her skin. She was admitted for asthma exacerbation and lower extremity cellulitis. She improved with fluids, albuterol nebulizers, methylprednisolone, and ceftriaxone/doxycycline. During her next 2 hospital days, she had a lower extremity ultrasound that was negative for a deep vein thrombosis and a transthoracic echocardiogram that was normal except for biatrial enlargement.

At midnight of her second hospital day, the patient's son noted that his mother was feeling dizzy. Four hours later, the patient suddenly became bradycardic to a heart rate of 20 beats per minute. Walking to the bathroom, she was notably dyspneic, with an oxygen saturation of 87%. She then became unresponsive. Her initial rhythm was pulseless electrical activity. During the code, a senior resident placed an intraosseous (IO) line in the left tibia following several unsuccessful attempts to obtain peripheral venous access. After 10 minutes of chest compressions and advanced cardiovascular life support protocol, spontaneous circulation returned and the patient was transferred to the intensive care unit (ICU).

Three hours after the IO line was placed, a nurse notified the primary team that the left leg was a dusky purple, and on examination the leg was bluish and tensely edematous with sluggish distal pulses. Vascular surgery diagnosed compartment syndrome, removed the IO line, and performed a bedside fasciotomy later that morning. The fasciotomy wounds were slow to heal and required ongoing complex care. After 2 months in the ICU and multiple complications, the patient was discharged.

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