Intraosseous anomalous drainage: a rare case of pretibial varicose vein / Drenagem anômala intraóssea: um caso raro de varizes pré-tibiais

ABSTRACT Valve failure with reflux and post-thrombotic syndrome are the factors most commonly correlated with varicose disease. Other rare etiologies can be put forward when these two main causes are ruled out. We report a case in which a young man presented chronic pain in the left tibia, varicose veins in the lower limbs and frequent occurrences of erysipelas. During investigation of the etiology of the varicose veins, radiographs and magnetic resonance imaging of the left leg were requested. These showed images suggestive of an osteolytic lesion in the tibia, but led us to the diagnosis of an intraosseous vein with anomalous drainage. This was confirmed through vascular examinations comprising Doppler venous flow measurement and phlebography. Recognition of this rare intraosseous anomaly is fundamental for proper patient management, but an intraosseous surgical approach is unnecessary.

RESUMO Incompetência valvar com refluxo e síndrome pós-trombótica são os fatores mais comumente relacionados à doença varicosa. Outras raras etiologias podem ser levantadas quando essas duas principais causas são descartadas. Relatamos o caso de um homem jovem com dor crônica na tíbia esquerda, varizes em membros inferiores e erisipela de repetição. Durante investigação da etiologia das varizes foram solicitadas radiografias e ressonância da perna esquerda, que evidenciaram imagens sugestivas de uma lesão osteolítica na tíbia, mas que nos levaram ao diagnóstico de veia intraóssea com drenagem anômala, confirmado pelos exames vasculares de dopplerfluxometria venosa e flebografia. O reconhecimento dessa rara anomalia intraóssea é fundamental para o manejo adequado do paciente, não necessita de abordagem cirúrgica intraóssea.

Experience of Using the Intraosseous Access to Critical Pediatric Patients in a Tertiary Emergency Department

PURPOSE: Intraosseous infusion is a safe and effective vascular access route in critically ill patients, especially in the pediatric population. Use of intraosseous access has shown a recent increase in Korea, but this procedure is not well reported. The aim of this study is to evaluate the clinical characteristics and outcomes of intraosseous infusion. METHODS: This study was a retrospective chart review of pediatric patients who received intraosseous infusion at a tertiary emergency department between April 2010 and March 2014. Their clinical characteristics and outcomes were evaluated. RESULTS: A total of 30 patients participated; 25 patients were cardiac arrest, three were status epilepticus, one was septic shock, and one was severe hypovolemic shock. Final procedure success rate was 90% and average 1.63 attempts were performed per child. Finally 12 patients survived over 24 hours. In particular, all patients of non-cardiac arrest survived and were discharged successfully from our hospital. Median maintenance time of the intraosseous device among survived patients was 112 minutes. No complications were reported. CONCLUSION: Intraosseous infusion in the emergency department was a very effective procedure for cardiac arrested patients and critically ill patients in whom access to the vascular route was difficult.

Educational effect of intraosseous access for medical students / 한국의학교육

PURPOSE: The purpose of this study was to determine the educational effects of intraosseous (IO) vascular access for medical students and analyze the possibility of including IO access in medical education. METHODS: A before-and-after study was conducted in a course with 50 participating medical students. The course comprised a 1-hour didactic lecture and a 1-hour hands-on session with a battery-operated EZ-IO device (Vidacare Corp.) and artificial tibia. After the course, the participant skills were tested (final success rate, mean procedural time, and detailed skills) with regard to IO access. Before and after the course, the knowledge, possibility of clinical use, and adequacy of medical education on IO access were examined in a structured questionnaire. RESULTS: The final success rate of insertion was 88% (n=44), and the mean procedural time for the first trial was 78.1+/-20.6 seconds. "Combination needle with drill" and "proper angle during insertion" were the procedures that were performed the best, and "dressing on insertion site" was the worst-performed procedure. "Proper location of landmarks" was the only significant skill factor that was related to the success of IO access between those who succeeded and failed (p<0.05). In the analysis of the structured questionnaire, median knowledge score, possibility for clinical use, and adequacy of IO access in medical education increased significantly after the course (p<0.01). CONCLUSION: The educational effect of IO access for medical students was tremendous, and the knowledge of and attitude toward IO access improved significantly after the training course. We consider IO access to be adequate for medical education in Korea.

Intraosseous line insertion education effectiveness for pediatric and emergency medicine residents / 소아과

PURPOSE: This study aimed to assess current knowledge of and training experiences with the intraosseous (IO) line among emergency medicine (EM) and pediatric residents who care for critically ill children and to evaluate the educational effectiveness of the IO line workshop. METHODS: During May and June 2008 , a workshops on IO line insertion was held for EM and pediatric residents. The workshop comprised a 45-min lecture and a 15-min hands-on session. Asemi-drill type EZ-IO machine was used for education. Self-assessment questionnaires gauged residents knowledge of and experiences with IO line insertion or bone marrow (BM) examination and their confidence with IO line insertion before and after the workshop. Performance tests were completed for skill evaluation. RESULTS: Forty-five pediatric residents and 22 EM residents participated in the workshop. The pre-educational questionnaire revealed that EM residents had more educational experience in IO line insertion than pediatric residents (p<0.001), while pediatric residents reported more experience in BM examination (p<0.001). The post-educational questionnaire showed a statistically significant higher percentage of correct answers (p<0.001). Although the pediatric residents inserted an IO line more quickly (P=0.001), most residents (88.7%) succeeded in IO line insertion on their first attempt; there was no difference in the groups success rates. Both groups showed higher confidence in performing IO line insertion after training (p<0.001). CONCLUSION: Observed educational effectiveness in both knowledge and confidence of IO line insertion skill suggest educational opportunities for pediatric and EM residents should be increased.

Difficult Situation on Complete Response to Sudden Infant Death in Korea - Suggestion of Plans to Overcome

PURPOSE: To call on health authorities to construct an organized surveillance and investigation system with national financial support for sudden unexpected infant death (SUID) in Korea. METHODS: A single-center retrospective study was conducted on 19 SUID cases, including an analysis of vital statistics for Korean infants, estimation of costs, and suggestion of plans. RESULTS: SUID is the second most common cause of infant deaths in the ER. Most of the deceased infants in this study were discovered in a prone position and bystanders had not in any of the cases started cardiopulmonary resuscitation (CPR) at the scene. Immediate intraosseous (IO) access was not performed in the ER. All cases were categorized as "unclassified sudden infant death" according to the San Diego definition because autopsies and various screening tests were not performed. The assumed rate of incidence of SUID in Korea is 0.3~0.56 per 1000 live births per year. The cost for a response per SUID case was estimated to be over one million won. CONCLUSION: 1) Immediate launching of nation-wide "back-to-sleep campaign" is urgent. 2) Certification in infant resuscitation and prevention of sudden infant death syndrome (SIDS) should be required for workers in day care centers, orphanages or caregivers companies. 3) IO access should be performed immediately for infant cardiac arrest cases in the ER. 4) A nation-wide campaign would also be helpful to change irrational ideas about dead bodies, get public agreement on performing autopsies and raising the autopsy rate. 5) Legislation should be promoted to mandate autopsies and to organize and maintain a surveillance and investigation system with multi-agency support.