Comparison of routes for achieving parenteral access with a focus on the management of patients with Ebola virus disease

Abstract

BackgroundDehydration is an important cause of death in patients with Ebola virus disease (EVD). Parenteral fluids are often required in patients with fluid requirements in excess of their oral intake. The peripheral intravenous route is the most commonly used method of parenteral access, but inserting and maintaining an intravenous line can be challenging in the context of EVD. Therefore it is important to consider the advantages and disadvantages of different routes for achieving parenteral access (e.g. intravenous, intraosseous, subcutaneous and intraperitoneal).ObjectivesTo compare the reliability, ease of use and speed of insertion of different parenteral access methods.Search methodsWe ran the search on 17 November 2014. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, Ovid MEDLINE(R) and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP), CINAHL (EBSCOhost), clinicaltrials.gov and screened reference lists.Selection criteriaRandomised controlled trials comparing different parenteral routes for the infusion of fluids or medication.Data collection and analysisTwo review authors examined the titles and abstracts of records obtained by searching the electronic databases to determine eligibility. Two review authors extracted data from the included trials and assessed the risk of bias. Outcome measures of interest were success of insertion; time required for insertion; number of insertion attempts; number of dislodgements; time period with functional access; local site reactions; clinicians' perception of ease of administration; needlestick injury to healthcare workers; patients' discomfort; and mortality. For trials involving the administration of fluids we also collected data on the volume of fluid infused, changes in serum electrolytes and markers of renal function. We rated the quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach for the following outcomes: success of insertion, time required for insertion, number of dislodgements, volume of fluid infused and needlestick injuries.Main resultsWe included 17 trials involving 885 participants. Parenteral access was used to infuse fluids in 11 trials and medications in six trials. None of the trials involved patients with EVD. Intravenous and intraosseous access was compared in four trials; intravenous and subcutaneous access in 11; peripheral intravenous and intraperitoneal access in one; saphenous vein cutdown and intraosseous access in one; and intraperitoneal with subcutaneous access in one. All of the trials assessing the intravenous method involved peripheral intravenous access.We judged few trials to be at low risk of bias for any of the assessed domains.Compared to the intraosseous group, patients in the intravenous group were more likely to experience an insertion failure (risk ratio (RR) 3.89, 95% confidence interval (CI) 2.39 to 6.3...

Subcutaneous Infusion of Fluids for Hydration or Nutrition: A Review

“…In summary, the available evidence suggests that subcutaneous infusion can be an effective technique for the administration of fluids for hydration or nutrition, with minimal complications. Consistent with the findings of a recent Cochrane Review, which compared different methods of parenteral access for administering fluids or medications, our review also highlights that subcutaneous infusion can provide an alternative means of administering fluids when IV access is difficult or not possible. Furthermore, subcutaneous infusion has several advantages over IV infusion, including ease of application in multiple settings, low cost, and the lack of potential serious complications, particularly infections.…”

Strengthening Health Systems While Responding to a Health Crisis: Lessons Learned by a Nongovernmental Organization During the Ebola Virus Disease Epidemic in Sierra Leone

“…Debates regarding the reasons underlying such divergent outcomes will continue [ 16 , 17 , 52 – 54 ]. Yet it is clear that when patients have access to modern medicine, even without taking into account experimental drugs (such as specific antivirals, monoclonal antibodies, or small interfering RNA molecules), EVD is a treatable disease; the vast majority of patients infected with Ebola in West Africa did not—and still do not—have such access [ 55 , 56 ].…”

Comparison of Two Intraosseous Access Devices Employed During Simulated Cardiopulmonary Resuscitation. A Prospective, Randomized, Crossover, Manikin Study

“…Intraosseous injection provides entry for resuscitation drugs and fluid resuscitation [12][13][14]. However, flow through the IO catheter must be initiated by an initial flush of at least 10 mL of saline and maintained with the use of a pressure infusion bag inflated at 300 mmHg in accordance with the instructions of use [15].…”