Compartment syndrome following intraosseous infusion

Intraosseous infusion is a valuable technique in the resuscitation of critically ill pediatric patients in whom vascular access has proved otherwise impossible. Although it is well established as a safe and reliable means of emergent access, intraosseous infusion is not without danger, nor complication. One of the rare yet most grave complications of intraosseous access is compartment syndrome. We report a case of compartment syndrome as a result of intraosseous infusion that serves to remind of the potential pitfalls of this technique. An otherwise healthy 6-year-old girl presented to our institution's pediatric intensive care unit following emergent resuscitation for a prolonged cardiac arrest. Approximately 1 hour following an uneventful soccer practice, without any antecedent cardiopulmonary symptoms or complaints, the patient collapsed and was unresponsive, not breathing, and pulseless. In the course of resuscitation, right and left tibial intraosseous lines were started. After 30 minutes of resuscitation, with multiple rounds of lidocaine and epinephrine infused through the intraosseous lines, a sustained perfusing rhythm was established. Acute compartment syndrome was diagnosed, and through anterolateral and posteromedial incisions, all 4 fascial compartments were released. While the condition of the patient's extremity improved, the overall clinical condition of the patient did not. This case highlights the fundamental principles regarding the use of intraosseous infusion and the diagnosis and management of compartment syndrome in critically ill patients.