Pharmacokinetic effects of endotracheal, intraosseous, and intravenous epinephrine in a swine model of traumatic cardiac arrest

Burgert, James; Johnson, A. R.; O'Sullivan, Joseph; Blalock, Wayne J.; Duffield, Brent C.; Albright, Brian P.; Herzog, Cory C.; Moore, Matthew S.; Dempster, Katelyn S.; Rauch, Japeth W.

doi:10.1016/j.ajem.2019.02.035

Cited by 22 publications

(21 citation statements)

References 53 publications

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“…Using a swine model of traumatic cardiac arrest, Burgert et al concluded that the pharmacokinetics of epinephrine for humeral IOs and sternal IOs were statistically equivalent to PIV. 19 In the same study, maximum epinephrine concentration – C(max) – and time to maximum epinephrine concentration – T(max) – were significantly longer in the tibial IO group as compared to the sternal IO, humeral IO, and PIV groups. Hoskins et al had similar findings in a cardiac arrest with ongoing cardiopulmonary resuscitation (CPR) swine model.…”

Section: Discussionmentioning

confidence: 84%

“…As with other IO devices in civilian settings, the sternal IO is indicated when vascular access is necessary, but PIV has failed or is not readily accessible. 19 Historically, the use of sternal IO in young children has been associated with higher rates of anatomy-related complications such as increased risk of damage to retrosternal structures and low flow due to small marrow reservoir. 3 , 30 Currently, sternal IOs are only US Food and Drug Administration-approved for patients aged 12 years and older.…”

Section: Discussionmentioning

confidence: 99%

“… 17 – 18 However, it is more traditionally used as an option for vascular access, after failed PIV attempts. 8 , 19 There are several reasons for the device-selection priority recommendations listed in the guideline literature. While a PIV can be left in place for several days, IO devices are not recommended to be left in place for more than 24 hours.…”

Section: Introductionmentioning

confidence: 99%

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Sternal Intraosseous Devices: Review of the Literature

Laney¹,

Friedman²,

Fisher³

2021

WJEM

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Introduction The intraosseous (IO) route is one of the primary means of vascular access in critically ill and injured patients. The most common sites used are the proximal humerus, proximal tibia, and sternum. Sternal IO placement remains an often-overlooked option in emergency and prehospital medicine. Due to the conflicts in Afghanistan and Iraq the use of sternal IOs have increased. Methods The authors conducted a limited review, searching PubMed and Google Scholar databases for “sternal IO,” “sternal intraosseous,” and “intraosseous” without specific date limitations. A total of 47 articles were included in this review. Results Sternal IOs are currently FDA approved for ages 12 and older. Sternal IO access offers several anatomical, pharmacokinetic, hemodynamic, and logistical advantages over peripheral intravenous and other IO points of access. Sternal IO use carries many of the same risks and limitations as the humeral and tibial sites. Sternal IO gravity flow rates are sufficient for transfusing blood and resuscitation. In addition, studies demonstrated they are safe during active CPR. Conclusion The sternal IO route remains underutilized in civilian settings. When considering IO vascular access in adults or older children, medical providers should consider the sternum as the recommended IO access, particularly if the user is a novice with IO devices, increased flow rates are required, the patient has extremity trauma, or administration of a lipid soluble drug is anticipated.

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Section: Discussionmentioning

confidence: 84%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Sternal Intraosseous Devices: Review of the Literature

Laney¹,

Friedman²,

Fisher³

2021

WJEM

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“…absorption of epinephrine was highly variable and unreliable in the adult (Burgert et al, 2019;. Our study expanded on their findings with the addition of a pediatric group.…”

mentioning

confidence: 86%

“…Further, Zuercher et al showed a significant improvement in survival, better neurological outcome, and better 24-hour survivability when epinephrine was given earlier (Zuercher et al, 2011). In two separate studies, Burgert et al and Orlowski et al found that the absorption of epinephrine was highly variable and unreliable in an adult hypovolemic model (Burgert et al, 2019;Orlowski, Porembka, Gallagher, Lockrem, & VanLente, 1990). However, these studies did not include a pediatric model.…”

Section: Need For Vascular Accessmentioning

confidence: 99%

Effects of Endotracheal Administration of Epinephrine in Cardiac Arrest of Adult and Pediatric Swine

Kertes¹,

Fillman²,

Krawczyk³

et al. 2019

MSHP

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BACKGROUND: Few studies have investigated the effects of hypovolemia on area under the curve (AUC) and the return of spontaneous circulation (ROSC) comparing adults and children in cardiac arrest.AIMS: To compare the epinephrine endotracheal (ET) administration relative to AUC, rate, time to, and odds of achieving ROSC between hypovolemic adult and pediatric cardiac arrest models.METHODS: This was an experimental study using male Adult ET and Pediatric ET swine. Pediatric ET pigs (N=7) weighed 20-30 kg representing the average weight for a child between 5 and 6 years of age. Adult ET pigs (N=7) weighed 60 to 80 kg. All were exsanguinated 35% of their blood volume. Swine were put into arrest for 2 minutes. Cardiopulmonary resuscitation (CPR) was initiated for 2 minutes; epinephrine was then administered. Blood samples were collected over 5 minutes. RESULTS: No significant difference occurred in AUC between the groups (p > 0.05). The Pediatric ET group had higher rates of ROSC and a shorter time to ROSC (p < 0.05). Pediatric ET group had a 15 times greater odds of achieving ROSC compared to the Adult ET group. CONCLUSION: Based on the results of this study, we recommend epinephrine administration via ET within the pediatric arrest model, but not for the adult.

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