Fractures complicating intraosseous access in pediatric patients – A systematic review

Introduction

Intraosseous (IO) access is a commonly used procedure in pediatric emergencies for establishingvascular access when alternative means, such as intravenous access, cannot be obtained. Likealternative routes, IO can be administered quickly and provides a route for medications, blood products,and fluids to be infused in emergency circumstances. While the use of IO is generally considered safewith minimal risks, potential complications can include compartment syndrome, infection, thrombosis, and fracture.

Methods

Following PRISMA guidelines, a comprehensive search was performed across various academicdatabases. Search parameters were restricted to exclude articles that where; non-English, non-full text,and not published between 1922 and 2022. Articles were included in analysis if they included patients from 0 to 18 and reported on both the patient outcomes and the procedural information.

Results

Following data synthesis (n = 27 articles [n = 1339 cases]), it was observed that the EZ-IO needle was thepredominant choice of access, accounting for 69.7 % of cases. The tibia emerged as the most frequentlyselected insertion site, utilized in 97 % of instances. Among the 226 cases that reported on laterality, a nearly equal distribution between left (114) and right (112) sides were observed. Most IO attempts were successful in accessing vascular access upon first attempt. There were 23 cases that required a second attempt to achieve access, and 4 cases necessitating 3 or more attempts. Within 1339 participants, a complication was reported in 105 cases, producing a complication rate of 7.8 %. Of those 105 complications, fracture occurred 7 times (6.67 %). When specifically isolating fracture as a complication resulting IO access, only 7 cases were reported, indicating an occurrence rate of 0.52 %.

Conclusion

This review supports the rarity of fracture as a complication following the use of an IO needle in pediatric age group, emphasizing the need for additional research to elucidate the underlying risk factors associated with fracture in these cases. Additionally, it underscores the importance of conducting further pathological investigations to gain insight into bone histology that may be indicative of IO access and/or fracture occurrence.