Intraosseous Access as the Sole Vascular Route for Emergency Laparotomy in Septic Shock: A Case Report with Perioperative Implications

Abstract

Failure to obtain vascular access in critically ill surgical patients represents a rare but life-threatening perioperative challenge. Intraosseous (IO) access is well established in emergency resuscitation but is seldom used as the primary vascular route during adult anesthesia. We describe a 63-year-old morbidly obese woman with septic shock secondary to gastrointestinal perforation and concurrent coronavirus disease 2019 infection in whom peripheral intravenous, central venous, and arterial access attempts failed despite repeated ultrasound-guided efforts by experienced clinicians. A proximal tibial IO line was established and served as the sole reliable vascular access for induction and maintenance of general anesthesia, vasopressor infusion, and administration of approximately 3 L of crystalloid during emergent exploratory laparotomy. The IO line remained functional postoperatively and enabled successful medication delivery during cardiac arrest, resulting in return of spontaneous circulation. Despite transient stabilization, the patient later died from multisystem organ failure. This case demonstrates that IO access can function as a dependable primary vascular route for anesthetic and resuscitative management during major adult surgery when conventional access is unobtainable. Early consideration of IO access may prevent delays in definitive surgical care in critically ill patients.