Effect of Intravenous Versus Intraosseous Access in Prehospital Cardiac Arrest

Nguyen, Linh; Suarez, Stephen; Daniels, Jessica; Sánchez, Cristina Arribas; Landry, Kim; Redfield, Colby

doi:10.1016/j.amj.2019.02.005

Cited by 15 publications

(11 citation statements)

References 10 publications

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“…4, 5). These observations are consistent with reports of significantly reduced ROSC rates among initial nonshockable, cardiac arrest victims treated via intraosseous access versus IV access 23 …”

Section: Discussionsupporting

confidence: 91%

Tibial Intraosseous Administration of Epinephrine Is Effective in Restoring Return of Spontaneous Circulation in a Pediatric Normovolemic But Not Hypovolemic Cardiac Arrest Model

et al. 2020

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ObjectiveWe compared the efficacy of tibial intraosseous (TIO) administration of epinephrine in a pediatric normovolemic versus hypovolemic cardiac arrest model to determine the incidence of return of spontaneous circulation (ROSC) and plasma epinephrine concentrations over time.MethodsThis experimental study evaluated the pharmacokinetics of epinephrine and/or incidence of ROSC after TIO administration in either a normovolemic or hypovolemic pediatric swine model.ResultsAll subjects in the TIO normovolemia cardiac arrest group experienced ROSC after TIO administration of epinephrine. In contrast, subjects experiencing hypovolemia and cardiac arrest were significantly less likely to experience ROSC when epinephrine was administered TIO versus intravenous (TIO hypovolemia: 14% [1/7] vs IV hypovolemia: 71% [5/7]; P = 0.031). The TIO hypovolemia group exhibited significantly lower plasma epinephrine concentrations versus IV hypovolemia at 60, 90, 120, and 150 seconds (P < 0.05). Although the maximum concentration of plasma epinephrine was similar, the TIO hypovolemia group exhibited significantly slower time to maximum concentration times versus TIO normovolemia subjects (P = 0.004).ConclusionsTibial intraosseous administration of epinephrine reliably facilitated ROSC among normovolemic cardiac arrest pediatric patients, which is consistent with published reports. However, TIO administration of epinephrine was ineffective in restoring ROSC among subjects experiencing hypovolemia and cardiac arrest. Tibial intraosseous–administered epinephrine during hypovolemia and cardiac arrest may have resulted in a potential sequestration of epinephrine in the tibia. Central or peripheral intravascular access attempts should not be abandoned after successful TIO placement in the resuscitation of patients experiencing concurrent hypovolemia and cardiac arrest.

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Section: Discussionsupporting

confidence: 91%

Tibial Intraosseous Administration of Epinephrine Is Effective in Restoring Return of Spontaneous Circulation in a Pediatric Normovolemic But Not Hypovolemic Cardiac Arrest Model

et al. 2020

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“…Our results also indicated that an IV route should also be established quickly for OHCA patients who have received a first-attempt and successful prehospital IO access. Additionally, our results indirectly supported some currently published evidence that the IV approach appears to be the optimal route for epinephrine administration in advanced life support for OHCA during resuscitation [8][9][10][11][12][13].…”

Section: Ta B L E 3 Logistic Regression For Sustained Rosc With Oddssupporting

confidence: 87%

“…Given the relative ease and speed with which it can be achieved, a higher successful placement rate compared with IV cannulation, and the relatively low procedural risk, intraosseous (IO) access has grown in popularity and is increasingly implemented as a first-line approach for drug administration during cardiac arrest [6,7]. However, recent observational studies support the theory that IV access appears to be the optimal route for epinephrine administration during resuscitation [8][9][10][11][12]. In a 2020 study by Zhang et al [13], where the IV or IO routes of OHCA patients were the first and only attempted route, IO treatment was associated with worse outcomes in comparison to an IV approach.…”

Section: Introductionmentioning

confidence: 99%

Effect of prehospital intraosseous combined with in-hospital intravenous access in out-of-hospital cardiac arrest

2021

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Objective: Obtaining vascular access during out-of-hospital cardiac arrest (OHCA) is challenging. The aim of this study was to compare the effectiveness of prehospital intraosseous infusion (IO) combined with in-hospital intravenous (IV) (pre-IO + in-IV) access versus the simple IV (pre-IV + in-IV) access in adult OHCA patients who do not achieve prehospital return of spontaneous circulation (ROSC). Methods: This retrospective observational study included adults with OHCA of presumed cardiac etiology between October 1, 2017-October 1, 2020 at an academic emergency department in China. All of the OHCA patients included within the study had Emergency Medical Services cardiopulmonary resuscitation and received prehospital epinephrine administration, but did not achieve prehospital ROSC. The study population were classified as either pre-IO + in-IV or IV (pre-IV + in-IV) based on their epinephrine administration route. The prehospital epinephrine routes were the first and only attempted route. The primary outcome investigated was sustained ROSC following arrival at the emergency department. The secondary outcome considered was the time from dispatch to the first epinephrine dose. Results: Of 193 included adult OHCA subjects who did not have prehospital ROSC, 128 received IV access only. The 65 pre-IO + in-IV-treated patients received epinephrine faster compared to IV-treated patients in terms of the median time from dispatch to the first injection of epinephrine (14.5 vs. 16.0 min, P = 0.001). In the pre-IO + in-IV group, 34 of 65 patients (52.3%) achieved sustained ROSC compared with 65 of 128 (50.8%) patients in the IV group (χ2 = 0.031, P = 0.841). There was no significant difference in sustained ROSC (adjusted OR1.049, 95% CI: 0.425-2.591, P = 0.918) between the two groups. Conclusion: A similar sustained ROSC rate was achieved for both the pre-IO + in-IV access group and the simple IV access group. Our results suggested that an IV route should be established quickly for prehospital IO-treated OHCA patients who do not achieve prehospital ROSC.

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“…16 Observational studies have had mixed outcomes, though they tend to favor intravenous over IO for ACLS drugs. [17][18][19][20] Meta-analysis of these studies favors intravenous over IO for ROSC and long-term survival after cardiac arrest. 21 In controlled swine models of cardiac arrest, time to ROSC and Pk analyses is equivalent for intravenous compared with various models of sternal and humeral IO for delivery of amiodarone, epinephrine and vasopressin.…”

Section: Discussionmentioning

confidence: 99%

Validation of intraosseous delivery of valproic acid in a swine model of polytrauma

Biesterveld

O’Connell

Kemp

et al. 2021

Trauma Surg Acute Care Open

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BackgroundIntraosseous (IO) drug delivery may be necessary in emergency situations when intravenous access is unattainable. Valproic acid (VPA) is a histone deacetylase inhibitor that has previously been shown to improve survival in preclinical models of lethal polytrauma. In this study, we sought to compare serum levels of intravenously and IO-delivered VPA, and to analyze the effect of IO-delivered VPA.MethodsSwine were subjected to 40% blood volume hemorrhage, brain injury, femur fracture, rectus crush injury and liver laceration. After 1 hour of shock, animals were randomized (n=3/group) to receive normal saline resuscitation (control), normal saline+intravenous VPA 150 mg/kg (intravenous group) or normal saline +IO VPA 150 mg/kg (IO group). Serum levels of VPA were assessed between groups, and proteomics analyses were performed on IO and control groups on heart, lung and liver samples.ResultsIntravenous and IO serum VPA levels were similar at 1, 3, 5 and 7 hours after starting the infusion (p>0.05). IO-delivered VPA induced significant proteomics changes in the heart, lung and liver, which were most pronounced in the lung. Biologic processes affected included inflammation, metabolism and transcriptional & translational machinery. The control group had 0% survival, and the intravenous and IO group both had 100% survival to the end of the experiment (p<0.05).DiscussionIO-delivered VPA is noninferior to intravenous administration and is a viable option in emergent situations when intravenous access is unattainable.Level of evidenceNot applicable (animal study).

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Effect of Intravenous Versus Intraosseous Access in Prehospital Cardiac Arrest

Cited by 15 publications

References 10 publications

Tibial Intraosseous Administration of Epinephrine Is Effective in Restoring Return of Spontaneous Circulation in a Pediatric Normovolemic But Not Hypovolemic Cardiac Arrest Model

Tibial Intraosseous Administration of Epinephrine Is Effective in Restoring Return of Spontaneous Circulation in a Pediatric Normovolemic But Not Hypovolemic Cardiac Arrest Model

Effect of prehospital intraosseous combined with in-hospital intravenous access in out-of-hospital cardiac arrest

Validation of intraosseous delivery of valproic acid in a swine model of polytrauma

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