Clinical evaluation of intravenous alone versus intravenous or intraosseous access for treatment of out-of-hospital cardiac arrest

Abstract

Objective: Obtaining vascular access during out-of-hospital cardiac arrest (OHCA) is challenging. The aim of this study was to determine if using intraosseous (IO) access when intravenous (IV) access fails improves outcomes. Methods: This was a prospective, parallel-group, cluster-randomised study that compared 'IV only' against 'IV + IO' in OHCA patients, where if 2 IV attempts failed or took more than 90 s, paramedics had 2 further attempts of IO. Primary outcome was any return of spontaneous circulation (ROSC). Secondary outcomes were insertion success rate, adrenaline administration, time to adrenaline and survival outcome. Results: A total of 1007 patients were included in the analysis. An Intention To Treat analysis showed a significant difference in success rates of obtaining vascular access in the IV + IO arm compared to the IV arm (76.6% vs 61.1% p = 0.001). There were significantly more patients in the IV + IO arm than the IV arm being administered prehospital adrenaline (71.3% vs 55.4% p = 0.001). The IV + IO arm also received adrenaline faster compared to the IV arm in terms of median time from emergency call to adrenaline (23 min vs 25 min p = 0.001). There was no significant difference in ROSC (adjusted OR 0.99 95%CI: 0.75À1.29), survival to discharge or survival with CPC 2 or better in both groups. A Per Protocol analysis also showed there was higher success in obtaining vascular access in the IV + IO arm, but ROSC and survival outcomes were not statistically different. Conclusion: Using IO when IV failed led to a higher rate of vascular access, prehospital adrenaline administration and faster adrenaline administration. However, it was not associated with higher ROSC, survival to discharge, or good neurological outcome.

Heart Disease and Stroke Statistics—2023 Update: A Report From the American Heart Association

“…203,204 An RCT comparing intravenous only with intravenous plus intraosseous administration of adrenaline in OHCA found a higher yield of vascular access with the addition of intraosseous access but no improvement in return of spontaneous circulation, survival, or neurological outcome. 205…”

Cardiac arrest: An interdisciplinary scoping review of clinical literature from 2020

“…A common theme of the prehospital literature from 2020 was the focus on timeliness in cardiac arrest management. Times to specific endpoints were the primary outcomes of interest in 9 articles 11–20 . Endpoints included time elapsed until recognition of cardiac arrest, contact with first responders, defibrillation, establishment of vascular access, epinephrine administration, resumption of chest compressions after pulse check, and definitive care in a hospital 11–20 .…”

“…Times to specific endpoints were the primary outcomes of interest in 9 articles 11–20 . Endpoints included time elapsed until recognition of cardiac arrest, contact with first responders, defibrillation, establishment of vascular access, epinephrine administration, resumption of chest compressions after pulse check, and definitive care in a hospital 11–20 . Overall, although a reduced time to each intervention during resuscitation was not uniformly shown to improve survival or neurologic outcome, no harms from more rapid intervention for each of the parameters listed above were noted.…”

“…[11][12][13][14][15][16][17][18][19][20] Endpoints included time elapsed until recognition of cardiac arrest, contact with first responders, defibrillation, establishment of vascular access, epinephrine administration, resumption of chest compressions after pulse check, and definitive care in a hospital. [11][12][13][14][15][16][17][18][19][20] Overall, although a reduced time to each intervention during resuscitation was not uniformly shown to improve survival or neurologic outcome, no harms from more rapid intervention for each of the parameters listed above were noted. Moreover, delays in arrival or in initiation of a given therapy continued to demonstrate increased odds of poor outcomes as measured by cerebral performance category (CPC).…”

Impact of intravenous accessibility and prehospital epinephrine use on survival outcomes of adult nontraumatic out-of-hospital cardiac arrest patients

“…For instance, a US study reported a 49% success rate on the first attempt [ 20 ], whereas a UK study reported an 81.6% success rate [ 21 ]. This variability is attributed to multiple factors, such as patient-related issues (e.g., collapsed veins, obesity, and fragile skin) and environmental challenges (e.g., limited space, moving ambulances, poor lighting, and difficult patient positioning) [ 22 , 23 ]. In Ulsan, EMS personnel appear to consider patient age and RTI when deciding on IV attempts, contributing to a relatively higher IV success rate.…”