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Chung J, Bundy J, Khan S, Hunt A, Carroll S, Ali A, Shafi N, Tesoro E. "Intraosseous administration of tenecteplase for thrombolysis of an acute ischemic stroke". J Stroke Cerebrovasc Dis 2024; 33:107850. [PMID: 38971481 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/28/2024] [Accepted: 07/03/2024] [Indexed: 07/08/2024] Open
Abstract
INTRO Current guidelines for acute ischemic stroke recommend timely administration of intravascular thrombolytic therapy to promote functional and neurologic outcomes. Tenecteplase is an emerging off-label therapy for this indication and being utilized by various institutions due to its simpler administration strategy. In emergent situations in which intravenous access cannot be obtained, intraosseous access is a viable option for medication administration. However, there has been minimal published cases to support the efficacy and safety of intraosseous administration of tenecteplase for acute ischemic stroke. CASE We describe the case of a 51-year-old woman who developed acute ischemic stroke within our institution. Due to difficulty achieving intravenous access and time-dependent efficacy of thrombolytic therapy, the decision was made to administer tenecteplase by the intraosseous route. Stroke symptoms improved within 48 hours following administration without complication. CONCLUSION Intraosseous administration of tenecteplase may be considered for treatment of acute ischemic stroke if intravenous access is unattainable.
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Affiliation(s)
- JinJoo Chung
- University of Illinois Hospital and Health Sciences System, United States; University of Illinois Chicago College of Pharmacy, United States.
| | - Jonathan Bundy
- University of Illinois Hospital and Health Sciences System, United States
| | - Sameera Khan
- University of Illinois Hospital and Health Sciences System, United States
| | - Aaron Hunt
- University of Illinois Chicago College of Pharmacy, United States
| | - Seth Carroll
- University of Illinois Hospital and Health Sciences System, United States; University of Illinois Chicago College of Pharmacy, United States
| | - Aisha Ali
- University of Illinois Hospital and Health Sciences System, United States
| | - Neelofer Shafi
- University of Illinois Hospital and Health Sciences System, United States
| | - Eljim Tesoro
- University of Illinois Hospital and Health Sciences System, United States; University of Illinois Chicago College of Pharmacy, United States
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Qasim ZA, Joseph B. Intraosseous access in the resuscitation of patients with trauma: the good, the bad, the future. Trauma Surg Acute Care Open 2024; 9:e001369. [PMID: 38646033 PMCID: PMC11029384 DOI: 10.1136/tsaco-2024-001369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 03/09/2024] [Indexed: 04/23/2024] Open
Abstract
The timely restoration of lost blood in hemorrhaging patients with trauma, especially those who are hemodynamically unstable, is of utmost importance. While intravenous access has traditionally been considered the primary method for vascular access, intraosseous (IO) access is gaining popularity as an alternative for patients with unsuccessful attempts. Previous studies have highlighted the higher success rate and easier training process associated with IO access compared with peripheral intravenous (PIV) and central intravenous access. However, the effectiveness of IO access in the early aggressive resuscitation of patients remains unclear. This review article aims to comprehensively discuss various aspects of IO access, including its advantages and disadvantages, and explore the existing literature on the clinical outcomes of patients with trauma undergoing resuscitation with IO versus intravenous access.
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Affiliation(s)
- Zaffer A Qasim
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Bellal Joseph
- Department of Surgery, The University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
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Nilsson FN, Bie-Bogh S, Milling L, Hansen PM, Pedersen H, Christensen EF, Knudsen JS, Christensen HC, Folke F, Høen-Beck D, Væggemose U, Brøchner AC, Mikkelsen S. Association of intraosseous and intravenous access with patient outcome in out-of-hospital cardiac arrest. Sci Rep 2023; 13:20796. [PMID: 38012312 PMCID: PMC10682403 DOI: 10.1038/s41598-023-48350-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 11/25/2023] [Indexed: 11/29/2023] Open
Abstract
Here we report the results of a study on the association between drug delivery via intravenous route or intraosseous route in out-of-hospital cardiac arrest. Intraosseous drug delivery is considered an alternative option in resuscitation if intravenous access is difficult or impossible. Intraosseous uptake of drugs may, however, be compromised. We have performed a retrospective cohort study of all Danish patients with out-of-hospital cardiac arrest in the years 2016-2020 to investigate whether mortality is associated with the route of drug delivery. Outcome was 30-day mortality, death at the scene, no prehospital return of spontaneous circulation, and 7- and 90-days mortality. 17,250 patients had out-of-hospital cardiac arrest. 6243 patients received no treatment and were excluded. 1908 patients had sustained return of spontaneous circulation before access to the vascular bed was obtained. 2061 patients were unidentified, and 286 cases were erroneously registered. Thus, this report consist of results from 6752 patients. Drug delivery by intraosseous route is associated with increased OR of: No spontaneous circulation at any time (OR 1.51), Death at 7 days (OR 1.94), 30 days (2.02), and 90 days (OR 2.29). Intraosseous drug delivery in out-of-hospital cardiac arrest is associated with overall poorer outcomes than intravenous drug delivery.
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Affiliation(s)
- Frederik Nancke Nilsson
- The Prehospital Research Unit, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Søren Bie-Bogh
- OPEN, Open Patient Data Explorative Network, University of Southern Denmark, Odense, Denmark
| | - Louise Milling
- The Prehospital Research Unit, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, North Zealand Hospital, Hillerød, Denmark
| | - Peter Martin Hansen
- The Prehospital Research Unit, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- The Danish Air Ambulance, Aarhus, Denmark
| | - Helena Pedersen
- The Prehospital Research Unit, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Erika F Christensen
- Department of Clinical Medicine, Centre for Prehospital and Emergency Research, Aalborg University Hospital, Aalborg University, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jens Stubager Knudsen
- The Danish Air Ambulance, Aarhus, Denmark
- Department of Anaesthesiology, Kolding University Hospital, Kolding, Denmark
| | - Helle Collatz Christensen
- Prehospital Center, University of Copenhagen, Naestved, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Danish Clinical Quality Program (RKKP), National Clinical Registries, Copenhagen, Denmark
| | - Fredrik Folke
- Copenhagen Emergency Medical Services, University of Copenhagen, Ballerup, Denmark
- Department of Cardiology, Herlev Gentofte University Hospital, Copenhagen, Denmark
| | - David Høen-Beck
- Department of Anaesthesiology, Denmark and Prehospital Center, Holbæk Hospital, HolbækRegion Zealand, Denmark
| | - Ulla Væggemose
- Department of Research and Development, Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne Craveiro Brøchner
- The Prehospital Research Unit, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Anaesthesiology, Kolding University Hospital, Kolding, Denmark
| | - Søren Mikkelsen
- The Prehospital Research Unit, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark.
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, 5000, Odense C, Denmark.
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Monaco T, Fischer M, Michael M, Hubar I, Westenfeld R, Rauch S, Gräsner JT, Bernhard M. Impact of the route of adrenaline administration in patients suffering from out-of-hospital cardiac arrest on 30-day survival with good neurological outcome (ETIVIO study). Scand J Trauma Resusc Emerg Med 2023; 31:14. [PMID: 36997973 PMCID: PMC10061896 DOI: 10.1186/s13049-023-01079-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 03/21/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Over the past decades, international guidelines for cardiopulmonary resuscitation (CPR) have changed the recommendation for alternative routes for drug administration. Until now, evidence for the substantial superiority of one route with respect to treatment outcome after CPR has been lacking. The present study compares the effects of intravenous (IV), intraosseous (IO) and endotracheal (ET) adrenaline application during CPR in out-of-hospital cardiac arrest (OHCA) on clinical outcomes within the database of the German Resuscitation Registry (GRR). METHODS This registry analysis was based on the GRR cohort of 212,228 OHCA patients between 1989 and 2020. Inclusion criteria were: OHCA, application of adrenaline, and out-of-hospital CPR. Excluded from the study were patients younger than 18 years, those who had trauma or bleeding as suspected causes of cardiac arrest, and incomplete data sets. The clinical endpoint was hospital discharge with good neurological outcome [cerebral performance category (CPC) 1/2]. Four routes of adrenaline administration were compared: IV, IO, IO + IV, ET + IV. Group comparisons were done using matched-pair analysis and binary logistic regression. RESULTS In matched-pair group comparisons of the primary clinical outcome hospital discharge with CPC 1/2, the IV group (n = 2416) showed better results compared to IO (n = 1208), [odds ratio (OR): 2.43, 95% confidence interval (CI): 1.54-3.84, p < 0.01] and when comparing IV (n = 8706) to IO + IV (n = 4353), [OR: 1.33, 95% CI: 1.12-1.59, p < 0.01]. In contrast, no significant difference was found between IV (n = 532) and ET + IV (n = 266), [OR: 1.26, 95% CI: 0.55-2.90, p = 0.59]. Concurrently, binary logistic regression yielded a highly significant effect of vascular access type (χ² = 67.744(3), p < 0.001) on hospital discharge with CPC1/2, with negative effects for IO (regression coefficient (r.c.) = - 0.766, p = 0.001) and IO + IV (r.c. = - 0.201, p = 0,028) and no significant effect for ET + IV (r.c. = 0.117, p = 0.770) compared to IV. CONCLUSIONS The GRR data, collected over a period of 31 years, seem to emphasize the relevance of an IV access during out-of-hospital CPR, in the event that adrenaline had to be administered. IO administration of adrenaline might be less effective. ET application, though removed in 2010 from international guidelines, could gain importance as an alternative route again.
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Affiliation(s)
- Tobias Monaco
- Emergency Department, University Hospital of Düsseldorf, Heinrich Heine University, Moorenstrasse 5, D-40225, Düsseldorf, Germany
| | - Matthias Fischer
- Department of Anaesthesiology and Intensive Care, ALB FILS Kliniken, Eichertstraße 3, 73035, Göppingen, Germany
| | - Mark Michael
- Emergency Department, University Hospital of Düsseldorf, Heinrich Heine University, Moorenstrasse 5, D-40225, Düsseldorf, Germany
| | - Iryna Hubar
- Emergency Department, University Hospital of Düsseldorf, Heinrich Heine University, Moorenstrasse 5, D-40225, Düsseldorf, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hsopital of Düsseldorf, Heinrich Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Stefan Rauch
- Department of Anaesthesiology and Intensive Care, ALB FILS Kliniken, Eichertstraße 3, 73035, Göppingen, Germany
| | - Jan-Thorsten Gräsner
- Institute for Emergency Medicine, Department of Anesthesiology and Intensive Care Medicine, University-Hospital Schleswig-Holstein, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital of Düsseldorf, Heinrich Heine University, Moorenstrasse 5, D-40225, Düsseldorf, Germany.
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Wang D, Deng L, Zhang R, Zhou Y, Zeng J, Jiang H. Efficacy of intraosseous access for trauma resuscitation: a systematic review and meta-analysis. World J Emerg Surg 2023; 18:17. [PMID: 36918947 PMCID: PMC10012735 DOI: 10.1186/s13017-023-00487-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 02/28/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND During medical emergencies, intraosseous (IO) access and intravenous (IV) access are methods of administering therapies and medications to patients. Treating patients in emergency medical situations is a highly time sensitive practice; however, research into the optimal access method is limited and existing systematic reviews have only considered out-of-hospital cardiac arrest (OHCA) patients. We focused on severe trauma patients and conducted a systematic review to evaluate the efficacy and efficiency of intraosseous (IO) access compared to intravenous (IV) access for trauma resuscitation in prehospital care. MATERIALS AND METHOD PubMed, Web of Science, Cochrane Library, EMBASE, ScienceDirect, banque de données en santé publique and CNKI databases were searched for articles published between January 1, 2000, and January 31, 2023. Adult trauma patients were included, regardless of race, nationality, and region. OHCA patients and other types of patients were excluded. The experimental and control groups received IO and IV access, respectively, in the pre-hospital and emergency departments for salvage. The primary outcome was success rate on first attempt, which was defined as secure needle position in the marrow cavity or a peripheral vein, with normal fluid flow. Secondary outcomes included mean time to resuscitation, mean procedure time, and complications. RESULTS Three reviewers independently screened the literature, extracted the data, and assessed the risk of bias in the included studies; meta-analyses were then performed using Review Manager (Version 5.4; Cochrane, Oxford, UK). The success rate on first attempt was significant higher for IO access than for IV access (RR = 1.46, 95% CI [1.16, 1.85], P = 0.001). The mean procedure time was significantly reduced (MD = - 5.67, 95% CI [- 9.26, - 2.07], P = 0.002). There was no significant difference in mean time to resuscitation (MD = - 1.00, 95% CI [- 3.18, 1.17], P = 0.37) and complications (RR = 1.22, 95% CI [0.14, 10.62], P = 0.86) between the IO and IV groups. CONCLUSION The success rate on first attempt of IO access was much higher than that of IV access for trauma patients, and the mean procedure time of IO access was significantly less when compared to IV access. Therefore, IO access should be suggested as an urgent vascular access for hypotensive trauma patients, especially those who are under severe shock.
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Affiliation(s)
- Dong Wang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China
| | - Lei Deng
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China.,Sichuan Province Clinical Research Center for Emergency and Critical Care Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Ruipeng Zhang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China
| | - Yiyue Zhou
- Department of Biology, Sorbonne University, 75005, Paris, France
| | - Jun Zeng
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China.,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China.,Sichuan Province Clinical Research Center for Emergency and Critical Care Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Hua Jiang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China. .,Chinese Academy of Sciences, Sichuan Translational Medicine Research Hospital, Chengdu, 610072, China. .,Sichuan Province Clinical Research Center for Emergency and Critical Care Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China.
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Matte AE, Vossenberg NE, Akers KG, Paxton JH. Intraosseous Vascular Access in Cardiac Arrest: A Systematic Review of the Literature, with Implications for Future Research. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2023. [DOI: 10.1007/s40138-023-00259-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
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Ibarra Romero M, Sánchez-García JC, Cavazzoli E, Tovar-Gálvez MI, Cortés-Martín J, Martínez-Heredia N, Rodríguez-Blanque R. Nursing Staff Knowledge on the Use of Intraosseous Vascular Access in Out-Of-Hospital Emergencies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2175. [PMID: 36767541 PMCID: PMC9915301 DOI: 10.3390/ijerph20032175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 01/18/2023] [Accepted: 01/22/2023] [Indexed: 06/18/2023]
Abstract
In healthcare practice, there may be critically injured patients in whom catheterisation of a peripheral venous access is not possible. In these cases, intraosseous access may be the preferred technique, using an intraosseous vascular access device (IOVA). Such devices can be used for infusion or administration of drugs in the same way as other catheterisations, which improves emergency care times, as it is a procedure that can be performed in seconds to a minute. The aim of this study was to analyse the level of knowledge of nursing staff working in emergency departments regarding the management of the intraosseous vascular access devices. To this end, a cross-sectional online study was carried out using an anonymous questionnaire administered to all professionals working in emergency and critical care units (ECCUs) in Granada district (Spain). The results show that 60% of the participants believe that with the knowledge they have, they would not be able to perform intraosseous vascular access, and 74% of the participants believe that the low use of this device is due to insufficient training. The obtained results suggest that the intraosseous access route, although it is a safe and quick way of achieving venous access in critical situations, is considered a secondary form of access because the knowledge of emergency and critical care professionals is insufficient, given the totality of the participants demanding more training in the management of intraosseous access devices. Therefore, the implementation of theoretical/practical training programmes related to intraosseous access (IO) could promote the continuous training of nurses working in ECCUs, in addition to improving the quality of care in emergency and critical care situations.
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Affiliation(s)
| | - Juan Carlos Sánchez-García
- Research Group CTS1068, Andalusia Research Plan, Junta de Andalucía, 18071 Granada, Spain
- School of Nursing, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain
| | | | - María Isabel Tovar-Gálvez
- Research Group CTS1068, Andalusia Research Plan, Junta de Andalucía, 18071 Granada, Spain
- School of Nursing Ceuta Campus, Faculty of Health Sciences, University of Granada, 51001 Ceuta, Spain
| | - Jonathan Cortés-Martín
- Research Group CTS1068, Andalusia Research Plan, Junta de Andalucía, 18071 Granada, Spain
- School of Nursing, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain
| | - Nazaret Martínez-Heredia
- Departamento Pedagogía, Facultad de Ciencias de la Educación, Universidad de Granada, Campus de Cartuja s/n., 18071 Granada, Spain
| | - Raquel Rodríguez-Blanque
- Research Group CTS1068, Andalusia Research Plan, Junta de Andalucía, 18071 Granada, Spain
- School of Nursing, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain
- San Cecilio Clinical Hospital, 18071 Granada, Spain
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Attitudes towards the Utilization of Intraosseous Access in Prehospital and Emergency Medicine Nursing Personnel. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58081086. [PMID: 36013553 PMCID: PMC9413818 DOI: 10.3390/medicina58081086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Insertion of an intraosseous access device enables intravascular access for critically ill patients in a prehospital and emergency department setting even when intravenous access is not possible. The aim of our study was to assess the attitudes of prehospital and emergency department nursing staff towards the utilization of intraosseous access devices. Materials and Methods: We performed quantitative research using a closed-ended structured questionnaire distributed to prehospital unit and associated emergency department nursing staff serving a population of around 200,000 inhabitants. Results: We distributed 140 questionnaires, and 106 were returned and completed. Of these, 69 (65.1%) respondents needed more than three attempts to achieve peripheral intravenous access at least once in the last year and 29 (27.4%) required central venous access because of impossible intravenous access. In the last five years, 8 (7.5%) respondents used endotracheal route for administration of medications. Despite this, only 48 (45.3%) of respondents have ever used the intraosseous route. Also, 79 (74.5%) respondents received at least some training in obtaining IO access; however, 46 (43.4%) answered that education regarding intraosseous access is not sufficient, and 92 (86.8%) answered that they wanted additional training regarding intraosseous access. Conclusions: Prehospital and emergency department nursing staff are aware of the importance of intraosseous access and understand the need for additional education and certification in this field.
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Yauger YJ, Johnson MD, Mark J, Le T, Woodruff T, Silvey S, Revis J, Blouin D, O'Sullivan J, Brady K, Hensler JG, Johnson D. Tibial Intraosseous Administration of Epinephrine Is Effective in Restoring Return of Spontaneous Circulation in a Pediatric Normovolemic But Not Hypovolemic Cardiac Arrest Model. Pediatr Emerg Care 2022; 38:e1166-e1172. [PMID: 32453255 DOI: 10.1097/pec.0000000000002127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We 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. METHODS This experimental study evaluated the pharmacokinetics of epinephrine and/or incidence of ROSC after TIO administration in either a normovolemic or hypovolemic pediatric swine model. RESULTS All 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). CONCLUSIONS Tibial 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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Affiliation(s)
- Young J Yauger
- From the United States Army Graduate Program of Anesthesia Nursing, San Antonio, TX
| | - Michelle D Johnson
- From the United States Army Graduate Program of Anesthesia Nursing, San Antonio, TX
| | - Jordan Mark
- From the United States Army Graduate Program of Anesthesia Nursing, San Antonio, TX
| | - Tho Le
- From the United States Army Graduate Program of Anesthesia Nursing, San Antonio, TX
| | - Thomas Woodruff
- From the United States Army Graduate Program of Anesthesia Nursing, San Antonio, TX
| | - Stephanie Silvey
- From the United States Army Graduate Program of Anesthesia Nursing, San Antonio, TX
| | - James Revis
- From the United States Army Graduate Program of Anesthesia Nursing, San Antonio, TX
| | - Dawn Blouin
- From the United States Army Graduate Program of Anesthesia Nursing, San Antonio, TX
| | - Joseph O'Sullivan
- From the United States Army Graduate Program of Anesthesia Nursing, San Antonio, TX
| | - Kerianne Brady
- Department of Emergency Medicine, New York-Presbyterian/Queens, Flushing, NY
| | - Julie G Hensler
- From the United States Army Graduate Program of Anesthesia Nursing, San Antonio, TX
| | - Don Johnson
- From the United States Army Graduate Program of Anesthesia Nursing, San Antonio, TX
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10
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Awareness, current use and attitudes toward intraosseous access among physicians and nurses in China: a national web-based survey. Eur J Emerg Med 2022; 29:78-79. [PMID: 34932033 DOI: 10.1097/mej.0000000000000839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lee JA, Guieu LVS, Bussières G, Smith CK. Advanced Vascular Access in Small Animal Emergency and Critical Care. Front Vet Sci 2021; 8:703595. [PMID: 34912872 PMCID: PMC8666720 DOI: 10.3389/fvets.2021.703595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 11/08/2021] [Indexed: 11/17/2022] Open
Abstract
In canine and feline patients presenting in a state of hemodynamic collapse, obtaining vascular access can be challenging. Delays in achieving vascular access interfere with delivery of patient care. In human medicine, definitions of difficult vascular access are variable and include the need for multiple placement attempts or involvement of specialized teams and equipment. Incidence and risk factors for difficult vascular access have not been well studied in veterinary patients, which limits understanding of how best to address this issue. Alternatives to percutaneous peripheral or central intravenous catheterization in dogs and cats include venous cutdowns, umbilical access in newborns, corpus cavernosum access in males, ultrasound-guided catheterization, and intraosseous catheterization. In recent years, advances in ultrasonography and intraosseous access techniques have made these more accessible to veterinary practitioners. These vascular access techniques are reviewed here, along with advantages, limitations, and areas for future study of each technique.
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Affiliation(s)
- Jack A Lee
- Small Animal Clinical Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville, TN, United States
| | - Liz-Valéry S Guieu
- Small Animal Clinical Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville, TN, United States
| | - Geneviève Bussières
- Small Animal Clinical Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville, TN, United States
| | - Christopher K Smith
- Small Animal Clinical Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville, TN, United States
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Besserer F, Kawano T, Dirk J, Meckler G, Tijssen JA, DeCaen A, Scheuermeyer F, Beno S, Christenson J, Grunau B. The association of intraosseous vascular access and survival among pediatric patients with out-of-hospital cardiac arrest. Resuscitation 2021; 167:49-57. [PMID: 34389454 DOI: 10.1016/j.resuscitation.2021.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 05/10/2021] [Accepted: 08/01/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION In pediatric out-of-hospital cardiac arrest (OHCA) the effect of intraosseous (IO) or intravenous (IV) access on outcomes is unclear. METHODS We analyzed prospectively collected data of non-traumatic OHCA in the Resuscitation Outcomes Consortium registry from 2011 to 2015. We included EMS-treated patients ≤17 years of age, classified patients based on vascular access routes, and calculated success rates of IO and IV attempts. After excluding patients with obvious non-cardiac etiologies and those with unsuccessful vascular access or multiple routes, we fit a logistic regression model to evaluate the association of IO vascular access (reference IV access) with the primary outcome of survival, using multiple imputation to address missing data. We analyzed a subgroup of patients at least 2 years of age. RESULTS There were 1549 non-traumatic OHCA: 895 (57.8%) patients had an IO line attempted with 822 (91.8%) successful; 488 (31.5%) had an IV line attempted with 345 (70.7%) successful (difference 21%, 95% CI 17 to 26%). Of the 761 patients included in our logistic regression, 601 received IO (30 [5.2%] survived) and 160 received IV (40 [25%] survived) vascular access. Intraosseous access was associated with a decreased probability of survival (adjusted OR 0.46; 95% CI 0.21-0.98). Patients at least 2 years of age showed a similar association (adjusted OR 0.36; CI 0.15-0.86). CONCLUSIONS Intraosseous access was associated with decreased survival among pediatric non-traumatic OHCA. These results are exploratory and support the need for further study to evaluate the effect of intravascular access method on outcomes.
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Affiliation(s)
- Floyd Besserer
- Department of Emergency Medicine, University of British Columbia, Canada; BC Emergency Health Services, British Columbia, Canada; Canadian Resuscitation Outcomes Consortium, Canada.
| | - Takahisa Kawano
- Canadian Resuscitation Outcomes Consortium, Canada; Department of Emergency Medicine, University of Fukui Hospital, Fukui Prefecture, Japan
| | - Justin Dirk
- School of Medicine, Queen's University, Ontario, Canada
| | - Garth Meckler
- Department of Emergency Medicine, University of British Columbia, Canada; BC Emergency Health Services, British Columbia, Canada; Canadian Resuscitation Outcomes Consortium, Canada; Department of Pediatrics, University of British Columbia, Canada
| | - Janice A Tijssen
- Canadian Resuscitation Outcomes Consortium, Canada; Department of Paediatrics, Western University, Canada
| | - Allan DeCaen
- Canadian Resuscitation Outcomes Consortium, Canada; Department of Paediatrics, University of Alberta, Canada
| | - Frank Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Canada; Canadian Resuscitation Outcomes Consortium, Canada; Centre for Health Evaluation and Outcome Sciences, Canada
| | - Suzanne Beno
- Department of Paediatrics, University of Toronto, Canada
| | - Jim Christenson
- Department of Emergency Medicine, University of British Columbia, Canada; Canadian Resuscitation Outcomes Consortium, Canada; Centre for Health Evaluation and Outcome Sciences, Canada
| | - Brian Grunau
- Department of Emergency Medicine, University of British Columbia, Canada; BC Emergency Health Services, British Columbia, Canada; Canadian Resuscitation Outcomes Consortium, Canada; Centre for Health Evaluation and Outcome Sciences, Canada
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13
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Schwalbach KT, Yong SS, Chad Wade R, Barney J. Impact of intraosseous versus intravenous resuscitation during in-hospital cardiac arrest: A retrospective study. Resuscitation 2021; 166:7-13. [PMID: 34273470 DOI: 10.1016/j.resuscitation.2021.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/22/2021] [Accepted: 07/04/2021] [Indexed: 11/20/2022]
Abstract
AIM To compare outcomes between Intraosseous (IO) and peripheral intravenous (PIV) injection during in-hospital cardiac arrest (IHCA) and examine its utility in individuals with obesity. METHODS We performed a retrospective cohort analysis of adult, atraumatic IHCA at a single tertiary care center. Subjects were classified as either IO or PIV resuscitation. The primary outcome of interest was survival to hospital discharge. The secondary outcomes of interest were survival with favourable neurologic status, rates-of-ROSC (ROR) and time-to-ROSC (TTR). Subgroup analysis among patients with BMI ≥ 30 kg/m2 was performed. RESULTS Complete data were available for 1852 subjects, 1039 of whom met eligibility criteria. A total of 832 were resuscitated via PIV route and 207 via IO route. Use of IO compared to PIV was associated with lower overall survival to hospital discharge (20.8% vs 28.4% p = 0.03), lower rates of survival with favourable neurologic status (18.4% vs 25.2% p = 0.04), lower ROR (72.2% vs 80.7%) and longer TTR (12:38 min vs 9:01 min). After multivariate adjustment there was no significant differences between IO and PIV in rates of survival to discharge (OR 0.71, 95% CI 0.47-1.06, p = 0.09) or rates of survival with favourable neurologic status (OR 0.74, 95% CI 0.49-1.13, p = 0.16). The ROR and TTR remained significantly worse in the IO group. Subgroup analysis of patients with BMI ≥ 30 kg/m2 identified no benefit or harm with use of IO compared to PIV. CONCLUSION Intraosseous medication delivery is associated with inferior rates-of-ROSC and longer times-to-ROSC compared to PIV, but no differences in overall survival to hospital discharge or survival with favourable neurologic status during IHCA.
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Affiliation(s)
- Kevin T Schwalbach
- University of Alabama at Birmingham, Department of Medicine, 1720 2nd Ave South, BDB 321, Birmingham, AL 35294-0012, United States
| | - Sylvia S Yong
- University of Alabama at Birmingham, Department of Medicine, 1720 2nd Ave South, BDB 321, Birmingham, AL 35294-0012, United States
| | - R Chad Wade
- University of Alabama at Birmingham Division of Pulmonary, Allergy and Critical Care Medicine, 1900 University Blvd., Tinsley Harrison Tower, Suite 422, Birmingham, AL 35294, United States
| | - Joseph Barney
- University of Alabama at Birmingham Division of Pulmonary, Allergy and Critical Care Medicine, 1900 University Blvd., Tinsley Harrison Tower, Suite 422, Birmingham, AL 35294, United States.
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14
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Laney JA, Friedman J, Fisher AD. Sternal Intraosseous Devices: Review of the Literature. West J Emerg Med 2021; 22:690-695. [PMID: 34125048 PMCID: PMC8202990 DOI: 10.5811/westjem.2020.12.48939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/06/2020] [Indexed: 11/22/2022] Open
Abstract
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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Affiliation(s)
- Jared A Laney
- Texas A&M University College of Medicine, Bryan, Texas
| | | | - Andrew D Fisher
- Medical Command, Texas Army National Guard, Austin, Texas.,University of New Mexico School of Medicine, Department of Surgery, Albuquerque, New Mexico
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15
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Royale With Adrenalin: Intraosseous Versus IV Vascular Access for Out-of-Hospital Cardiac Arrest Resuscitation Epinephrine. Pediatr Crit Care Med 2021; 22:332-334. [PMID: 33657616 DOI: 10.1097/pcc.0000000000002672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Intraosseous or Peripheral IV Access in Pediatric Cardiac Arrest? Results From the French National Cardiac Arrest Registry. Pediatr Crit Care Med 2021; 22:286-296. [PMID: 33433156 DOI: 10.1097/pcc.0000000000002659] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Despite the evolving recommendations that favor the use of intraosseous access in pediatric resuscitation, the impact of vascular access type on survival in young children has not been demonstrated. The aim of this study was to assess the impact of the intravascular injection route on the return on spontaneous circulation, survival to hospital admission (0 day), and 30 days or survival to hospital discharge, by comparing survival rates in young children having intraosseous and peripheral IV access. The second aim was to compare the rates of favorable neurologic outcome after 30 days or survival to hospital discharge. DESIGN This was a multicenter retrospective comparative study between July 2011 and October 2018. SETTING Based on the French cardiac arrest registry data. PATIENTS All prepubescent (males < 12 yr old, females < 10 yr old) victims of an out-of-hospital cardiac arrest. INTERVENTIONS Patients with adrenaline administration by intraosseous versus peripheral venous technique were compared, using propensity score matching. MEASUREMENTS AND MAIN RESULTS The analysis included 603 prepubescent patients, 351 (58%) in the intraosseous group and 252 (42%) in the peripheral IV group. Intraosseous group patients were younger, lighter, with more medical cause for arrest. The intraosseous group had lower survival rates at 30 days or hospital discharge (n = 6; 1.7%) than the peripheral IV group (n = 12; 4.8%) (p = 0.030). After matching, 101 pairs of patients were created. No difference was observed on return of spontaneous circulation or 0-day survival rates (odds ratio = 1.000 [95% CI, 0.518-1.930]; odds ratio = 0.946 [95% CI, 0.492-1.817], respectively) and on 30 days or hospital discharge survival (n = 3 in both groups) (odds ratio = 1.000 [95% CI, 0.197-5.076]). Meaningful statistical evaluation of neurologic status among survivors was precluded by inadequate numbers. CONCLUSIONS The type of injection route (intraosseous or peripheral venous access) does not appear to have an impact on survival of out-of-hospital cardiac arrest in a prepubescent population, but limitations of propensity matching limit a definitive conclusion.
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Hinkelbein J, Kerkhoff S, Adler C, Ahlbäck A, Braunecker S, Burgard D, Cirillo F, De Robertis E, Glaser E, Haidl TK, Hodkinson P, Iovino IZ, Jansen S, Johnson KVL, Jünger S, Komorowski M, Leary M, Mackaill C, Nagrebetsky A, Neuhaus C, Rehnberg L, Romano GM, Russomano T, Schmitz J, Spelten O, Starck C, Thierry S, Velho R, Warnecke T. Cardiopulmonary resuscitation (CPR) during spaceflight - a guideline for CPR in microgravity from the German Society of Aerospace Medicine (DGLRM) and the European Society of Aerospace Medicine Space Medicine Group (ESAM-SMG). Scand J Trauma Resusc Emerg Med 2020; 28:108. [PMID: 33138865 PMCID: PMC7607644 DOI: 10.1186/s13049-020-00793-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With the "Artemis"-mission mankind will return to the Moon by 2024. Prolonged periods in space will not only present physical and psychological challenges to the astronauts, but also pose risks concerning the medical treatment capabilities of the crew. So far, no guideline exists for the treatment of severe medical emergencies in microgravity. We, as a international group of researchers related to the field of aerospace medicine and critical care, took on the challenge and developed a an evidence-based guideline for the arguably most severe medical emergency - cardiac arrest. METHODS After the creation of said international group, PICO questions regarding the topic cardiopulmonary resuscitation in microgravity were developed to guide the systematic literature research. Afterwards a precise search strategy was compiled which was then applied to "MEDLINE". Four thousand one hundred sixty-five findings were retrieved and consecutively screened by at least 2 reviewers. This led to 88 original publications that were acquired in full-text version and then critically appraised using the GRADE methodology. Those studies formed to basis for the guideline recommendations that were designed by at least 2 experts on the given field. Afterwards those recommendations were subject to a consensus finding process according to the DELPHI-methodology. RESULTS We recommend a differentiated approach to CPR in microgravity with a division into basic life support (BLS) and advanced life support (ALS) similar to the Earth-based guidelines. In immediate BLS, the chest compression method of choice is the Evetts-Russomano method (ER), whereas in an ALS scenario, with the patient being restrained on the Crew Medical Restraint System, the handstand method (HS) should be applied. Airway management should only be performed if at least two rescuers are present and the patient has been restrained. A supraglottic airway device should be used for airway management where crew members untrained in tracheal intubation (TI) are involved. DISCUSSION CPR in microgravity is feasible and should be applied according to the Earth-based guidelines of the AHA/ERC in relation to fundamental statements, like urgent recognition and action, focus on high-quality chest compressions, compression depth and compression-ventilation ratio. However, the special circumstances presented by microgravity and spaceflight must be considered concerning central points such as rescuer position and methods for the performance of chest compressions, airway management and defibrillation.
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Affiliation(s)
- Jochen Hinkelbein
- German Society of Aviation and Space Medicine (DGLRM), Munich, Germany. .,Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, 50937, Cologne, Germany. .,Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.
| | - Steffen Kerkhoff
- German Society of Aviation and Space Medicine (DGLRM), Munich, Germany.,Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, 50937, Cologne, Germany.,Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany
| | - Christoph Adler
- Department of Internal Medicine III, Heart Centre of the University of Cologne, Cologne, Germany.,Fire Department City of Cologne, Institute for Security Science and Rescue Technology, Cologne, Germany
| | - Anton Ahlbäck
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.,Department of Anaesthesia and Intensive Care, Örebro University Hospital, Örebro, Sweden
| | - Stefan Braunecker
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.,Department of Anesthesiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Daniel Burgard
- Department of Cardiology and Angiology, Heart Center Duisburg, Evangelisches Klinikum Niederrhein, Duisburg, Germany
| | - Fabrizio Cirillo
- Department of Anaesthesia and Intensive Care, Santa Maria delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Edoardo De Robertis
- Division of Anaesthesia, Analgesia, and Intensive Care, Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Eckard Glaser
- German Society of Aviation and Space Medicine (DGLRM), Munich, Germany.,Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.,, Gerbrunn, Germany
| | - Theresa K Haidl
- Department of Psychiatry and Psychotherapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937, Cologne, Germany
| | - Pete Hodkinson
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.,Aerospace Medicine, Centre of Human and Applied Physiological Sciences, King's College, London, UK
| | - Ivan Zefiro Iovino
- Department of Anaesthesia and Intensive Care, Santa Maria delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Stefanie Jansen
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Cologne, 50937, Cologne, Germany
| | | | - Saskia Jünger
- Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health (CERES), University of Cologne and University Hospital of Cologne, Cologne, Germany
| | - Matthieu Komorowski
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.,Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Exhibition road, London, SW7 2AZ, UK
| | - Marion Leary
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Christina Mackaill
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.,Accident and Emergency Department, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Alexander Nagrebetsky
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Christopher Neuhaus
- German Society of Aviation and Space Medicine (DGLRM), Munich, Germany.,Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.,Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Lucas Rehnberg
- University Hospital Southampton NHS Foundation Trust, Anaesthetic Department, Southampton, UK
| | | | - Thais Russomano
- Centre of Human and Applied Physiological Sciences, Kings College London, London, UK
| | - Jan Schmitz
- German Society of Aviation and Space Medicine (DGLRM), Munich, Germany.,Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, 50937, Cologne, Germany.,Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany
| | - Oliver Spelten
- Department of Anaesthesiology and Intensive Care Medicine, Schön Klinik Düsseldorf, Am Heerdter Krankenhaus 2, 40549, Düsseldorf, Germany
| | - Clément Starck
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.,Anesthesiology Department, Brest University Hospital, Brest, France
| | - Seamus Thierry
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.,Anesthesiology Department, Bretagne Sud General Hospital, Lorient, France.,Medical and Maritime Simulation Center, Lorient, France.,Laboratory of Psychology, Cognition, Communication and Behavior, University of Bretagne Sud, Vannes, France
| | - Rochelle Velho
- Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, University Hospitals Birmingham, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Tobias Warnecke
- University Department for Anesthesia, Intensive and Emergency Medicine and Pain Management, Hospital Oldenburg, Oldenburg, Germany
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Abstract
BACKGROUND Obtaining intravascular access can be challenging or even impossible in several clinical situations. As an alternative, medications and fluids can be administered via the intraosseous (IO) route, which is a well-tolerated and established alternative, especially in the emergency setting. METHODS Seventy-five novice physicians participated in this randomized simulation study. After a single educational session and 6 months without any clinical application, participants were asked to identify the correct puncture site and obtain IO access using 3 widely used mechanical devices (BIG Pediatric, Arrow EZ-IO, NIO Pediatric) and a manual device (Jamshidi needle) on a pediatric manikin and turkey bone, respectively. RESULTS Sixty-eight participants correctly identified the puncture site and performed IO cannulations. First placement attempt success rate was similar with mechanical devices (NIO Pediatric, 100%; Arrow EZ-IO, 97%; and BIG Pediatric, 90%), whereas was only 43% using the manual Jamshidi device. Also, procedure time was much faster using mechanical devices (ranging between 18 and 23 seconds) compared with the manual Jamshidi device (34 seconds). CONCLUSIONS Although the efficacy of devices was demonstrated in simulated environment in novice users, further studies are needed to assess the efficacy and safety of devices in clinical comparative settings. With more experienced users, the success rate may differ considerably as compared with naive users.
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19
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Baert V, Vilhelm C, Escutnaire J, Nave S, Hugenschmitt D, Chouihed T, Tazarourte K, Javaudin F, Wiel E, El Khoury C, Hubert H. Intraosseous Versus Peripheral Intravenous Access During Out-of-Hospital Cardiac Arrest: a Comparison of 30-Day Survival and Neurological Outcome in the French National Registry. Cardiovasc Drugs Ther 2020; 34:189-197. [DOI: 10.1007/s10557-020-06952-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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20
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Intravenous vs. intraosseous administration of drugs during cardiac arrest: A systematic review. Resuscitation 2020; 149:150-157. [PMID: 32142750 DOI: 10.1016/j.resuscitation.2020.02.025] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/12/2020] [Accepted: 02/19/2020] [Indexed: 01/22/2023]
Abstract
AIM To perform a systematic review of the literature on intravenous (IV) vs. intraosseous (IO) administration of drugs during cardiac arrest in order to inform an update of international guidelines. METHODS The review was performed according to PRISMA guidelines and registered on PROSPERO. Medline, Embase and Evidence-Based Medicine Reviews were searched on December 17, 2019 for studies comparing IV to IO administration of drugs. The population included neonatal, paediatric, and adult patients with cardiac arrest. Two investigators reviewed each search for study relevance, extracted data, and assessed the risk of bias of individual studies. Meta-analyses were performed for studies without a critical risk of bias. Certainty of evidence was evaluated using GRADE. RESULTS We included six observational studies comparing IV to IO administration of drugs and two randomized trials assessing the effect of specific drugs in subgroups related to IV vs. IO administration. All studies included adult out-of-hospital cardiac arrest patients. No studies were identified in neonatal or paediatric patients. The risk of bias for the observational studies was overall assessed as critical or serious, with confounding and selection bias being the primary sources of bias. The meta-analyses excluding studies with a critical risk of bias favoured IV access for all outcomes. Using GRADE, the certainty of evidence was judged at very low. Subgroup analyses of the two randomized trials demonstrated no statistically significant interactions between the route of access and study drugs on outcomes. However, these trials were underpowered to assess such interactions. CONCLUSIONS We identified a limited number of studies comparing IV vs. IO administration of drugs during cardiac arrest. Pooled results from four observational studies favoured IV access with very low certainty of evidence. From the subgroup analyses of two randomized clinical trials, there was no statistically significant interaction between the route of access and study drug on outcomes.
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21
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Morgan RW, Berg RA. Intraosseous adrenaline for adult out-of-hospital cardiac arrest: Faster access with worse outcomes. Resuscitation 2020; 149:238-239. [PMID: 32084571 DOI: 10.1016/j.resuscitation.2020.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 02/12/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Ryan W Morgan
- The Children's Hospital of Philadelphia, Anesthesiology and Critical Care Medicine, 34th Street & Civic Center Blvd., South Tower-Rm#7C26, Philadelphia, PA 19104-4399, United States
| | - Robert A Berg
- The Children's Hospital of Philadelphia, Anesthesiology and Critical Care Medicine, 34th Street & Civic Center Blvd., South Tower-Rm#7C26, Philadelphia, PA 19104-4399, United States.
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22
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Neill MJ, Burgert JM, Blouin D, Tigges B, Rodden K, Roberts R, Anderson P, Hallquist T, Navarro J, O'Sullivan J, Johnson D. Effects of humeral intraosseous epinephrine in a pediatric hypovolemic cardiac arrest porcine model. Trauma Surg Acute Care Open 2020; 5:e000372. [PMID: 32154374 PMCID: PMC7046964 DOI: 10.1136/tsaco-2019-000372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/04/2019] [Accepted: 12/10/2019] [Indexed: 11/25/2022] Open
Abstract
Background Aims of the study were to determine the effects of humerus intraosseous (HIO) versus intravenous (IV) administration of epinephrine in a hypovolemic, pediatric pig model. We compared concentration maximum (Cmax), time to maximum concentration (Tmax), mean concentration (MC) over time and return of spontaneous circulation (ROSC). Methods Pediatric pig were randomly assigned to each group (HIO (n=7); IV (n=7); cardiopulmonary resuscitation (CPR)+defibrillation (defib) (n=7) and CPR-only group (n=5)). The pig were anesthetized; 35% of the blood volume was exsanguinated. pigs were in arrest for 2 min, and then CPR was performed for 2 min. Epinephrine 0.01 mg/kg was administered 4 min postarrest by either route. Samples were collected over 5 min. After sample collection, epinephrine was administered every 4 min or until ROSC. The Cmax and MC were analyzed using high-performance liquid chromatography. Defibrillation began at 3 min postarrest and administered every 2 min or until ROSC or endpoint at 20 min after initiation of CPR. Results Analysis indicated that the Cmax was significantly higher in the IV versus HIO group (p=0.001). Tmax was shorter in the IV group but was not significantly different (p=0.789). The MC was significantly greater in the IV versus HIO groups at 90 and 120 s (p<0.05). The IV versus HIO had a significantly higher MC (p=0.001). χ2 indicated the IV group (5 out of 7) had significantly higher rate of ROSC than the HIO group (1 out of 7) (p=0.031). One subject in the CPR+defib and no subjects in the CPR-only groups achieved ROSC. Discussion Based on the results of our study, the IV route is more effective than the HIO route.
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Affiliation(s)
- Michael James Neill
- US Army Graduate Program in Anesthesia Nursing, US Army Medical Department, Fort Sam Houston, Texas, USA
| | - James M Burgert
- Department of Continuing EducationEvidence-based Healthcare Program, University of Oxford Kellogg College, Oxford, Oxfordshire, UK
| | | | - Benjamin Tigges
- US Army Graduate Program in Anesthesia Nursing, US Army Medical Department, Fort Sam Houston, Texas, USA
| | - Kari Rodden
- US Army Graduate Program in Anesthesia Nursing, US Army Medical Department, Fort Sam Houston, Texas, USA
| | - Rachel Roberts
- US Army Graduate Program in Anesthesia Nursing, US Army Medical Department, Fort Sam Houston, Texas, USA
| | - Phillip Anderson
- US Army Graduate Program in Anesthesia Nursing, US Army Medical Department, Fort Sam Houston, Texas, USA
| | - Travis Hallquist
- US Army Graduate Program in Anesthesia Nursing, US Army Medical Department, Fort Sam Houston, Texas, USA
| | - John Navarro
- US Army Graduate Program in Anesthesia Nursing, US Army Medical Department, Fort Sam Houston, Texas, USA
| | - Joseph O'Sullivan
- US Army Graduate Program in Anesthesia Nursing, US Army Medical Department, Fort Sam Houston, Texas, USA
| | - Don Johnson
- US Army Graduate Program in Anesthesia Nursing, US Army Medical Department, Fort Sam Houston, Texas, USA
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Liu C, Zhu J, Hai B, Zhang W, Wang H, Leng H, Xu Y, Song C. Single Intraosseous Injection of Simvastatin Promotes Endothelial Progenitor Cell Mobilization, Neovascularization, and Wound Healing in Diabetic Rats. Plast Reconstr Surg 2020; 145:433-443. [DOI: 10.1097/prs.0000000000006502] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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24
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Intraosseous versus intravenous administration of adrenaline in patients with out-of-hospital cardiac arrest: a secondary analysis of the PARAMEDIC2 placebo-controlled trial. Intensive Care Med 2020; 46:954-962. [PMID: 32002593 DOI: 10.1007/s00134-019-05920-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/26/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE To compare the effectiveness of the intravenous (IV) and intraosseous (IO) routes for drug administration in adults with a cardiac arrest enrolled in the Pre-Hospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug Administration in Cardiac Arrest (PARAMEDIC2) randomised, controlled trial. METHODS Patients were recruited from five National Health Service Ambulance Services in England and Wales from December 2014 through October 2017. Patients with an out-of-hospital cardiac arrest who were unresponsive to initial resuscitation attempts were randomly assigned to 1 mg adrenaline or matching placebo. Intravascular access was established as soon as possible, and IO access was considered if IV access was not possible after two attempts. RESULTS Among patients with out-of-hospital cardiac arrest, 3631 received adrenaline and 3686 received placebo. Amongst these, 1116 (30.1%) and 1121 (30.4%) received the study drug via the IO route. The odds ratios were similar in the IV and IO groups for return of spontaneous circulation (ROSC) at hospital handover [adjusted odds ratio (aOR) 4.07 (95% CI 3.42-4.85) and (aOR 3.98 (95% CI 2.86-5.53), P value for interaction 0.90]; survival to 30 days [aOR 1.67 (1.18-2.35) versus 0.9 (0.4-2.05), P = 0.18]; and favourable neurological outcome [aOR 1.39 (0.93-2.06) versus 0.62 (0.23-1.67), P = 0.14]. CONCLUSION There was no significant difference in treatment effect (adrenaline versus placebo) on ROSC at hospital handover between drugs administered by the intraosseous route or by the intravenous route. We could not detect any difference in the treatment effect between the IV and IO routes on the longer term outcomes of 30-day survival or favourable neurological outcome at discharge (ISRCTN73485024).
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Zhang Y, Zhu J, Liu Z, Gu L, Zhang W, Zhan H, Hu C, Liao J, Xiong Y, Idris AH. Intravenous versus intraosseous adrenaline administration in out-of-hospital cardiac arrest: A retrospective cohort study. Resuscitation 2020; 149:209-216. [PMID: 31982506 DOI: 10.1016/j.resuscitation.2020.01.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 12/22/2019] [Accepted: 01/06/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Adrenaline is an important component in the resuscitation of individuals experiencing out-of-hospital cardiac arrest (OHCA). The 2018 Advanced Cardiac Life Support (ACLS) algorithm gives the option of either intravenous (IV) or intraosseous (IO) routes for adrenaline administration during cardiac arrest. However, the optimal route during prehospital resuscitation remains controversial. This study aims to investigate whether IV and IO routes lead to different outcomes in OHCA patients who received prehospital adrenaline. METHODS This retrospective analysis included adult patients with OHCA of presumed cardiac origin who had Emergency Medical Services (EMS) CPR, received adrenaline, and were enrolled in the Resuscitation Outcomes Consortium (ROC) Cardiac Epistry version 3 database between 2011 and 2015. We divided the study population into IV and IO groups based on the administration route. Logistic regression analysis was performed to evaluate the association between adrenaline delivery routes and prehospital return of spontaneous circulation (ROSC), survival to hospital discharge, and favorable neurological outcome. RESULTS Of the 35,733 patients included, 27,758 (77.7%) had adrenaline administered via IV access and 7975 (22.3%) via IO access. With the IO group as a reference in the logistic regression model, the adjusted odds ratios of the IV group for prehospital ROSC, survival and favorable neurological outcome were 1.367 (95%CI, 1.276-1.464), 1.468 (95%CI, 1.264-1.705) and 1.849 (95%CI, 1.526-2.240), respectively. Similar results were found in the propensity score matched population and subgroup analysis. CONCLUSION Compared with the IO approach, the IV approach appears to be the optimal route for adrenaline administration in advanced life support for OHCA during prehospital resuscitation.
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Affiliation(s)
- Yongshu Zhang
- Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China
| | - Jieming Zhu
- Department of Cardiology, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou 510630, China
| | - Zhihao Liu
- Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China
| | - Liwen Gu
- Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China
| | - Wanwan Zhang
- Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China
| | - Hong Zhan
- Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China
| | - Chunlin Hu
- Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China
| | - Jinli Liao
- Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China.
| | - Yan Xiong
- Department of Emergency Medicine, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China; University of Texas, Southwestern Medical Center, 5323 Harry Hines BLVD, Dallas, Texas 75390-8579, USA.
| | - Ahamed H Idris
- University of Texas, Southwestern Medical Center, 5323 Harry Hines BLVD, Dallas, Texas 75390-8579, USA
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Daya MR, Leroux BG, Dorian P, Rea TD, Newgard CD, Morrison LJ, Lupton JR, Menegazzi JJ, Ornato JP, Sopko G, Christenson J, Idris A, Mody P, Vilke GM, Herdeman C, Barbic D, Kudenchuk PJ. Survival After Intravenous Versus Intraosseous Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Shock-Refractory Cardiac Arrest. Circulation 2020; 141:188-198. [PMID: 31941354 PMCID: PMC7009320 DOI: 10.1161/circulationaha.119.042240] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Antiarrhythmic drugs have not proven to significantly improve overall survival after out-of-hospital cardiac arrest from shock-refractory ventricular fibrillation/pulseless ventricular tachycardia. How this might be influenced by the route of drug administration is not known. METHODS In this prespecified analysis of a randomized, placebo-controlled clinical trial, we compared the differences in survival to hospital discharge in adults with shock-refractory ventricular fibrillation/pulseless ventricular tachycardia out-of-hospital cardiac arrest who were randomly assigned by emergency medical services personnel to an antiarrhythmic drug versus placebo in the ALPS trial (Resuscitation Outcomes Consortium Amiodarone, Lidocaine or Placebo Study), when stratified by the intravenous versus intraosseous route of administration. RESULTS Of 3019 randomly assigned patients with a known vascular access site, 2358 received ALPS drugs intravenously and 661 patients by the intraosseous route. Intraosseous and intravenous groups differed in sex, time-to-emergency medical services arrival, and some cardiopulmonary resuscitation characteristics, but were similar in others, including time-to-intravenous/intrasosseous drug receipt. Overall hospital discharge survival was 23%. In comparison with placebo, discharge survival was significantly higher in recipients of intravenous amiodarone (adjusted risk ratio, 1.26 [95% CI, 1.06-1.50]; adjusted absolute survival difference, 5.5% [95% CI, 1.5-9.5]) and intravenous lidocaine (adjusted risk ratio, 1.21 [95% CI, 1.02-1.45]; adjusted absolute survival difference, 4.7% [95% CI, 0.7-8.8]); but not in recipients of intraosseous amiodarone (adjusted risk ratio, 0.94 [95% CI, 0.66-1.32]) or intraosseous lidocaine (adjusted risk ratio, 1.03 [95% CI, 0.74-1.44]). Survival to hospital admission also increased significantly when drugs were given intravenously but not intraosseously, and favored improved neurological outcome at discharge. There were no outcome differences between intravenous and intraosseous placebo, indicating that the access route itself did not demarcate patients with poor prognosis. The study was underpowered to assess intravenous/intraosseous drug interactions, which were not statistically significant. CONCLUSIONS We found no significant effect modification by drug administration route for amiodarone or lidocaine in comparison with placebo during out-of-hospital cardiac arrest. However, point estimates for the effects of both drugs in comparison with placebo were significantly greater for the intravenous than for the intraosseous route across virtually all outcomes and beneficial only for the intravenous route. Given that the study was underpowered to statistically assess interactions, these findings signal the potential importance of the drug administration route during resuscitation that merits further investigation.
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Affiliation(s)
- Mohamud R. Daya
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
| | - Brian G. Leroux
- Department of Biostatistics, University of Washington Clinical Trial Center, Seattle, WA
| | - Paul Dorian
- Division of Cardiology St Michael’s Hospital, University of Toronto, Toronto, Canada
| | - Thomas D. Rea
- Department of Medicine, University of Washington, Seattle, WA
| | - Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
| | - Laurie J. Morrison
- Rescu, Li Ka Shing Knowledge Institute, St Michael’s Hospital, University of Toronto, Toronto, Canada
| | - Joshua R. Lupton
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
| | - James J. Menegazzi
- Department of Emergency Medicine, University of Pittsburgh School of Medicine
| | - Joseph P. Ornato
- Virginia Commonwealth University Health System, Richmond, Virginia
| | - George Sopko
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Jim Christenson
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Ahamed Idris
- Departments of Emergency Medicine and Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Purav Mody
- Division of Cardiology, Department of Internal medicine, UT Southwestern Medical Center, Dallas, TX USA
| | - Gary M. Vilke
- Department of Emergency Medicine, University of California San Diego, San Diego, CA
| | - Caroline Herdeman
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - David Barbic
- Centre for Health Evaluation Outcome Sciences, St Paul’s Hospital, Vancouver, Canada; University of British Columbia, Vancouver, Canada
| | - Peter J. Kudenchuk
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, WA
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Lange J, Boysen SR, Bentley A, Atilla A. Intraosseous Catheter Flow Rates and Ease of Placement at Various Sites in Canine Cadavers. Front Vet Sci 2019; 6:312. [PMID: 31608294 PMCID: PMC6761224 DOI: 10.3389/fvets.2019.00312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 09/02/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: To compare intraosseous catheter placement difficulty, success rates, and flow rates at four different locations in canine cadavers. Design: Prospective study. Setting: Private referral center. Animals: Eleven fresh canine cadavers. Interventions: With owner consent, animals presenting for euthanasia were recruited. Animals received heparin (1,000 IU/kg IV) at least 5 min prior to euthanasia. After euthanasia, EZIO intraosseous catheters were placed into the ilial wing, proximal medial tibia, proximal lateral humerus, and distal lateral femur on one side of the animal. Time to catheter placement and catheter difficulty were scored for each placement site. Sterile saline was infused into each location simultaneously over 5 min, first via gravity then using 300 mmHg pressure. Animals were repositioned onto the contra-lateral side and the experiment repeated. Measurements and Main Results: Placement was successful in 16/22 ilial, 18/22 tibial, and 22/22 femoral and humoral attempts. A post-hoc analysis revealed the ileum had a significantly greater difficulty score when compared to the femur and humerus (p ≤ 0.0001). The femur had a statistically significant faster placement time when compared to the ileum (p ≤ 0.05). Gravity infusion rates were statistically lower in the tibia when compared to humerus (p ≤ 0.01) and between the tibia when compared to the femur (p ≤0.001). Additionally, pressurized infusion rates were statistically lower in the tibia compared to the humerus (p ≤ 0.0001), the femur (p ≤ 0.0001), and the ileum (p ≤ 0.01). Conclusions: The femur and humerus had high success rate for IO catheter placement and low placement time and difficulty scores. Pressurized intraosseous flow rates were highest in the humerus and femur. Contrary to human literature, success rates for catheter placement in the humerus and femur were higher than at other sites, suggesting the humerus and femur may be preferred sites for intraosseous catheter placement in the dog. Further investigation through a larger sample size is required to confirm these findings.
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Affiliation(s)
- James Lange
- Department of Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada.,VCA Canada Western Veterinary Specialist and Emergency Centre, Calgary, AB, Canada
| | - Søren R Boysen
- Department of Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
| | - Adam Bentley
- VCA Canada Western Veterinary Specialist and Emergency Centre, Calgary, AB, Canada
| | - Aylin Atilla
- Department of Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
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Lin S, Dorian P. Interpreting observational data on adrenaline in cardiac arrest is complicated. Resuscitation 2019; 138:314-315. [DOI: 10.1016/j.resuscitation.2019.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 02/25/2019] [Indexed: 10/27/2022]
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Nguyen L, Suarez S, Daniels J, Sanchez C, Landry K, Redfield C. Effect of Intravenous Versus Intraosseous Access in Prehospital Cardiac Arrest. Air Med J 2019; 38:147-149. [PMID: 31122576 DOI: 10.1016/j.amj.2019.02.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 01/09/2019] [Accepted: 02/12/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The prevailing standard of care in prehospital emergency medical services (EMS) is that either intravenous (IV) or intraosseous (IO) access is an acceptable route for obtaining vascular access and delivery of resuscitation medications and volume expanders in cardiac arrest patients. The aim of this study was to evaluate the effectiveness of IV access versus IO access in terms of return of spontaneous circulation (ROSC) for patients suffering from cardiac arrest. METHODS A retrospective chart review examining cardiac arrest data with a single advanced life support EMS agency over a 4-year period was performed. Cardiac arrest patients were identified from a quality assurance database. Exclusion criteria included trauma arrest, pediatrics, pregnancy, and obvious signs of death. RESULTS A total of 795 patients remained after applying the exclusion criteria. A total of 183 (45.1%) out of 406 cardiac arrest patients achieved ROSC who had an IV placed. A total of 389 cardiac arrest patients had an IO placed with ROSC in 100 (25.7%). CONCLUSIONS Higher ROSC rates were achieved with IV access versus IO access. Limitations include the small sample size, a single EMS agency, and the retrospective nature of the study. Future studies should further evaluate the effectiveness of IO versus IV access in cardiac arrest and other low perfusion states.
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Affiliation(s)
- Linh Nguyen
- Florida State University College of Medicine, Tallahassee, FL
| | | | | | | | - Kim Landry
- Leon County Emergency Medical Services, Tallahassee, FL
| | - Colby Redfield
- Florida State University College of Medicine, Tallahassee, FL; Leon County Emergency Medical Services, Tallahassee, FL.
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Point-of-care laboratory analyses of intraosseous, arterial and central venous samples during experimental cardiopulmonary resuscitation. Resuscitation 2019; 137:124-132. [PMID: 30796917 DOI: 10.1016/j.resuscitation.2019.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/04/2019] [Accepted: 02/13/2019] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Screening and correcting reversible causes of cardiac arrest (CA) are an essential part of cardiopulmonary resuscitation (CPR). Point-of-care (POC) laboratory analyses are used for screening pre-arrest pathologies, such as electrolyte disorders and acid-base balance disturbances. The aims of this study were to compare the intraosseous (IO), arterial and central venous POC values during CA and CPR and to see how the CPR values reflect the pre-arrest state. METHODS We performed an experimental study on 23 anaesthetised pigs. After induction of ventricular fibrillation (VF), we obtained POC samples from the IO space, artery and central vein simultaneously at three consecutive time points. We observed the development of the values during CA and CPR and compared the CPR values to the pre-arrest values. RESULTS The IO, arterial and venous values changed differently from one another during the course of CA and CPR. Base excess and pH decreased in the venous and IO samples during untreated VF, but in the arterial samples, this only occurred after the onset of CPR. The IO, arterial and venous potassium values were higher during CPR compared to the pre-arrest arterial values (mean elevations 4.4 mmol/l (SD 0.72), 3.3 mmol/l (0.78) and 2.8 mmol/l (0.94), respectively). CONCLUSIONS A dynamic change occurs in the common laboratory values during CA and CPR. POC analyses of lactate, pH, sodium and calcium within IO samples are not different from analyses of arterial or venous blood. Potassium values in IO, arterial and venous samples during CPR are higher than the pre-arrest arterial values.
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Pharmacokinetic effects of endotracheal, intraosseous, and intravenous epinephrine in a swine model of traumatic cardiac arrest. Am J Emerg Med 2019; 37:2043-2050. [PMID: 30853153 DOI: 10.1016/j.ajem.2019.02.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 02/16/2019] [Accepted: 02/22/2019] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Limited prospective data exist regarding epinephrine's controversial role in managing traumatic cardiac arrest (TCA). This study compared the maximum concentration (Cmax), time to maximum concentration (Tmax), plasma concentration over time, return of spontaneous circulation (ROSC), time to ROSC, and odds of ROSC of epinephrine administered by the endotracheal (ETT), intraosseous (IO), and intravenous (IV) routes in a swine TCA model. METHODS Forty-nine Yorkshire-cross swine were assigned to seven groups: ETT, tibial IO (TIO), sternal IO (SIO), humeral IO (HIO), IV, CPR with defibrillation (CPRD), and CPR only. Swine were exsanguinated 31% of their blood volume and cardiac arrest induced. Chest compressions began 2 min post-arrest. At 4 min post-arrest, 1 mg epinephrine was administered, and blood specimens collected over 4 min. Resuscitation continued until ROSC or 30 min elapsed. RESULTS The Cmax of IV epinephrine was significantly higher than the TIO group (P = 0.049). No other differences in Cmax, Tmax, ROSC, and time to ROSC existed between the epinephrine groups (P > 0.05). Epinephrine levels were detectable in two of seven ETT swine. No significant difference in ROSC existed between the epinephrine groups and CPRD group (P > 0.05). Significant differences in ROSC existed between all groups and the CPR only group (P < 0.05). No significant differences in odds of ROSC were noted. CONCLUSIONS The pharmacokinetics of IV, HIO, and SIO epinephrine were comparable. Endotracheal epinephrine absorption was highly variable and unreliable compared to IV and IO epinephrine. Epinephrine appeared to have a lesser role than volume replacement in resuscitating TCA.
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Chalopin T, Lemaignen A, Guillon A, Geffray A, Derot G, Bahuaud O, Agout C, Rosset P, Castellier C, De Pinieux G, Valentin AS, Bernard L, Bastides F. Acute Tibial osteomyelitis caused by intraosseous access during initial resuscitation: a case report and literature review. BMC Infect Dis 2018; 18:665. [PMID: 30558553 PMCID: PMC6296120 DOI: 10.1186/s12879-018-3577-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 12/03/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intra-osseous (IO) access is recommended in cases of pre-hospital emergency or resuscitation when intravascular (IV) route is difficult or impossible. Despite recent improvement in IO devices and increasing indications, it remains rarely used in practice. Various complications have been reported but are uncommon. CASE PRESENTATION We report a case of massive acute tibial osteomyelitis in an adult male three months after an IO catheter insertion for emergency drug infusion. We review the literature on association between IO access and acute osteomyelitis in children and adults. CONCLUSIONS Emergency-care givers and radiologists should be informed about this infrequent complication in order to make early diagnosis and initiate adequate antibiotic therapy.
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Affiliation(s)
- Thomas Chalopin
- Department of Internal Medicine and Infectious Diseases, University Hospital of Tours, Hospital Bretonneau, Tours, France
- François Rabelais University, Tours, France
| | - Adrien Lemaignen
- Department of Internal Medicine and Infectious Diseases, University Hospital of Tours, Hospital Bretonneau, Tours, France
- François Rabelais University, Tours, France
| | - Antoine Guillon
- Department of Intensive Care Unit, University Hospital of Tours, Tours, France
| | - Arnaud Geffray
- Department of Medical Imaging, University Hospital of Tours, Tours, France
| | - Gaelle Derot
- Department of Medical Imaging, University Hospital of Tours, Tours, France
| | - Olivier Bahuaud
- Department of Internal Medicine and Infectious Diseases, University Hospital of Tours, Hospital Bretonneau, Tours, France
- François Rabelais University, Tours, France
| | - Charles Agout
- Department of Orthopedic Surgery, University Hospital of Tours, Tours, France
| | - Philippe Rosset
- Department of Orthopedic Surgery, University Hospital of Tours, Tours, France
| | - Claire Castellier
- Department of Anatomopathology, University Hospital of Tours, Tours, France
| | | | | | - Louis Bernard
- Department of Internal Medicine and Infectious Diseases, University Hospital of Tours, Hospital Bretonneau, Tours, France
- François Rabelais University, Tours, France
| | - Frederic Bastides
- Department of Internal Medicine and Infectious Diseases, University Hospital of Tours, Hospital Bretonneau, Tours, France
- François Rabelais University, Tours, France
- 2 boulevard Tonnellé, 37044 Tours, Cedex 9 France
| | - Centre De Référence Des Infections Ostéo-Articulaires Du Grand-Ouest (CRIOGO) Study Team
- Department of Internal Medicine and Infectious Diseases, University Hospital of Tours, Hospital Bretonneau, Tours, France
- François Rabelais University, Tours, France
- Department of Intensive Care Unit, University Hospital of Tours, Tours, France
- Department of Medical Imaging, University Hospital of Tours, Tours, France
- Department of Orthopedic Surgery, University Hospital of Tours, Tours, France
- Department of Anatomopathology, University Hospital of Tours, Tours, France
- Bacteriological Laboratory, University Hospital of Tours, Tours, France
- 2 boulevard Tonnellé, 37044 Tours, Cedex 9 France
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O'reilly M, Schmölzer GM. Evidence for vasopressors during cardiopulmonary resuscitation in newborn infants. Minerva Pediatr 2018; 71:159-173. [PMID: 30511562 DOI: 10.23736/s0026-4946.18.05452-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
An estimated 0.1% of term infants and up to 15% of preterm infants (2-3 million worldwide) need extensive resuscitation, defined as chest compression and 100% oxygen with or without epinephrine in the delivery room. Despite these interventions, infants receiving extensive resuscitation in the DR have a high incidence of mortality and neurologic morbidity. Successful resuscitation from neonatal cardiac arrest requires the delivery of high-quality chest compression using the most effective vasopressor with the optimal dose, timing, and route of administration during CPR. Current neonatal resuscitation guidelines recommend administration of epinephrine once CPR has started at a dose of 0.01-0.03 mg/kg preferably given intravenously, with repeated doses every 3-5 min until return of spontaneous circulation. This review examines the current evidence for epinephrine and alternative vasopressors during neonatal cardiopulmonary resuscitation.
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Affiliation(s)
- Megan O'reilly
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada.,Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Georg M Schmölzer
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada - .,Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
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Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Ann Emerg Med 2018; 71:588-596. [DOI: 10.1016/j.annemergmed.2017.11.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 11/09/2017] [Accepted: 11/14/2017] [Indexed: 12/21/2022]
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Abstract
OBJECTIVE During neonatal cardiopulmonary resuscitation, early establishment of vascular access is crucial. We aimed to review current evidence regarding different routes for the administration of medications during neonatal resuscitation. DATA SOURCES We reviewed PubMed, EMBASE, and Google Scholar using MeSH terms "catheterization," "umbilical cord," "delivery room," "catecholamine," "resuscitation," "simulation," "newborn," "infant," "intraosseous," "umbilical vein catheter," "access," "intubation," and "endotracheal." STUDY SELECTION Articles in all languages were included. Initially, we aimed to identify only neonatal studies and limited the search to randomized controlled trials. DATA EXTRACTION Due to a lack of available studies, studies in children and adults, as well as animal studies and also nonrandomized studies were included. DATA SYNTHESIS No randomized controlled trials comparing intraosseous access versus peripheral intravascular access versus umbilical venous catheter versus endotracheal tube versus laryngeal mask airway or any combination of these during neonatal resuscitation in the delivery room were identified. Endotracheal tube: endotracheal tube epinephrine administration should be limited to situations were no vascular access can be established. Laryngeal mask airway: animal studies suggest that a higher dose of epinephrine for endotracheal tube and laryngeal mask airway is required compared with IV administration, potentially increasing side effects. Umbilical venous catheter: European resuscitation guidelines propose the placement of a centrally positioned umbilical venous catheter during neonatal cardiopulmonary resuscitation; intraosseous access: case series reported successful and quick intraosseous access placement in newborn infants. Peripheral intravascular access: median time for peripheral intravascular access insertion was 4-5 minutes in previous studies. CONCLUSIONS Based on animal studies, endotracheal tube administration of medications requires a higher dose than that by peripheral intravascular access or umbilical venous catheter. Epinephrine via laryngeal mask airway is feasible as a noninvasive alternative approach for drug delivery. Intraosseous access should be considered in situations with difficulty in establishing other access. Randomized controlled clinical trials in neonates are required to compare all access possibilities described above.
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Burgert JM, Martinez A, O'Sullivan M, Blouin D, Long A, Johnson AD. Sternal Route More Effective than Tibial Route for Intraosseous Amiodarone Administration in a Swine Model of Ventricular Fibrillation. PREHOSP EMERG CARE 2017; 22:266-275. [PMID: 28910187 DOI: 10.1080/10903127.2017.1358782] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The pharmacokinetics of IO administered lipid soluble amiodarone during ventricular fibrillation (VF) with ongoing CPR are unknown. This study measured mean plasma concentration over 5 minutes, maximum plasma concentration (Cmax), and time to maximum concentration (Tmax) of amiodarone administered by the sternal IO (SIO), tibial IO (TIO), and IV routes in a swine model of VF with ongoing CPR. METHODS Twenty-one Yorkshire-cross swine were randomly assigned to three groups: SIO, TIO, and IV. Ventricular fibrillation was induced under general anesthesia. After 4 minutes in VF, 300 mg amiodarone was administered as indicated by group assignment. Serial blood specimens collected at 30, 60, 90, 120, 150, 180, 240, and 300 seconds were analyzed using high performance liquid chromatography with tandem mass spectrometry. RESULTS The mean plasma concentration of IV amiodarone over 5 minutes was significantly higher than the TIO group at 60 seconds (P = 0.02) and 90 seconds (P = 0.017) post-injection. No significant differences in Cmax between the groups were found (P <0.05). The Tmax of amiodarone was significantly shorter in the SIO (99 secs) and IV (86 secs) groups compared to the TIO group (215 secs); P = 0.002 and P = 0.002, respectively. CONCLUSIONS The SIO and IV routes of amiodarone administration were comparable. The TIO group took nearly three times longer to reach Tmax than the SIO and IV groups, likely indicating depot of lipid-soluble amiodarone in adipose-rich tibial yellow bone marrow. The SIO route was more effective than the TIO route for amiodarone delivery in a swine model of VF with ongoing CPR. Further investigations are necessary to determine if the kinetic differences found between the SIO and TIO routes in this study affect survival of VF in humans.
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Soar J, Nolan J, Böttiger B, Perkins G, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars M, Smith G, Sunde K, Deakin C. Erweiterte Reanimationsmaßnahmen für Erwachsene („adult advanced life support“). Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0330-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Feinstein BA, Stubbs BA, Rea T, Kudenchuk PJ. Intraosseous compared to intravenous drug resuscitation in out-of-hospital cardiac arrest. Resuscitation 2017. [PMID: 28629995 DOI: 10.1016/j.resuscitation.2017.06.014] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS Although the intraosseous (IO) route is increasingly used for vascular access in out-of-hospital cardiac arrest (OHCA), little is known about its comparative effectiveness relative to intravenous (IV) access. We evaluated clinical outcomes following OHCA comparing drug administration via IO versus IV routes. METHODS This retrospective cohort study evaluated Emergency Medical Services (EMS)-treated adults with atraumatic OHCA in a large metropolitan EMS system between 9/1/2012-12/31/2014. Access was classified as IO or IV based on the route of first EMS drug administration. Study endpoints were survival to hospital discharge, return of spontaneous circulation (ROSC) and survival to hospital admission. RESULTS Among 2164 adults with OHCA, 1800 met eligibility criteria, 1525 of whom were treated via IV and 275 principally via tibial-IO routes. Compared to IV, IO-treated patients were younger, more often women, had unwitnessed OHCA, a non-cardiac aetiology, and presented with non-shockable rhythms. IO versus IV-treated patients were less likely to survive to hospital discharge (14.9% vs 22.8%, p=0.003), achieve ROSC (43.6% vs 55.5%, p<0.001) or be hospitalized (38.5% vs 50.0% p<0.001). In multivariable adjusted analyses, IO treatment was not associated with survival to discharge (odds ratio (OR) (95% confidence interval) 0.81 (0.55, 1.21), p=0.31), but was associated with a lower likelihood of ROSC (OR=0.67 (0.50, 0.88), p=0.004) and survival to hospitalization (OR=0.68 (0.51, 0.91), p=0.009). CONCLUSION Though not independently associated with survival to discharge, principally tibial IO versus IV treatment was associated with a lower likelihood of ROSC and hospitalization. How routes of vascular access influence clinical outcomes after OHCA merits additional study.
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Affiliation(s)
| | - Benjamin A Stubbs
- Department of Family Medicine, University of Washington, United States
| | - Tom Rea
- Department of Medicine, University of Washington, United States
| | - Peter J Kudenchuk
- Department of Medicine, Division of Cardiology, University of Washington, Box 356422, 1959 NE Pacific Street, Seattle, WA, 98195-6422, United States.
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Nassar BS, Kerber R. Improving CPR Performance. Chest 2017; 152:1061-1069. [PMID: 28499516 DOI: 10.1016/j.chest.2017.04.178] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 04/07/2017] [Accepted: 04/27/2017] [Indexed: 01/21/2023] Open
Abstract
Cardiac arrest continues to represent a public health burden with most patients having dismal outcomes. CPR is a complex set of interventions requiring leadership, coordination, and best practices. Despite the widespread adoption of new evidence in various guidelines, the provision of CPR remains variable with poor adherence to published recommendations. Key steps health-care systems can take to enhance the quality of CPR and, potentially, to improve outcomes, include optimizing chest compressions, avoiding hyperventilation, encouraging intraosseous access, and monitoring capnography. Feedback devices provide instantaneous guidance to the rescuer, improve rescuer technique, and could impact patient outcomes. New technologies promise to improve the resuscitation process: mechanical devices standardize chest compressions, capnography guides resuscitation efforts and signals the return of spontaneous circulation, and intraosseous devices minimize interruptions to gain vascular access. This review aims at identifying a discreet group of interventions that health-care systems can use to raise their standard of cardiac resuscitation.
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Affiliation(s)
- Boulos S Nassar
- Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA.
| | - Richard Kerber
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
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The Resuscitative and Pharmacokinetic Effects of Humeral Intraosseous Vasopressin in a Swine Model of Ventricular Fibrillation. Prehosp Disaster Med 2017; 32:305-310. [PMID: 28270248 DOI: 10.1017/s1049023x17000140] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Introduction The American Heart Association (AHA; Dallas, Texas USA) and European Resuscitation Council (Niel, Belgium) cardiac arrest (CA) guidelines recommend the intraosseous (IO) route when intravenous (IV) access cannot be obtained. Vasopressin has been used as an alternative to epinephrine to treat ventricular fibrillation (VF). Hypothesis/Problem Limited data exist on the pharmacokinetics and resuscitative effects of vasopressin administered by the humeral IO (HIO) route for treatment of VF. The purpose of this study was to evaluate the effects of HIO and IV vasopressin, on the occurrence, odds, and time of return of spontaneous circulation (ROSC) and pharmacokinetic measures in a swine model of VF. METHODS Twenty-seven Yorkshire-cross swine (60 to 80 kg) were assigned randomly to three groups: HIO (n=9), IV (n=9), and a control group (n=9). Ventricular fibrillation was induced and untreated for two minutes. Chest compressions began at two minutes post-arrest and vasopressin (40 U) administered at four minutes post-arrest. Serial blood specimens were collected for four minutes, then the swine were resuscitated until ROSC or 29 post-arrest minutes elapsed. RESULTS Fisher's Exact test determined ROSC was significantly higher in the HIO 5/7 (71.5%) and IV 8/11 (72.7%) groups compared to the control 0/9 (0.0%; P=.001). Odds ratios of ROSC indicated no significant difference between the treatment groups (P=.68) but significant differences between the HIO and control, and the IV and control groups (P=.03 and .01, respectively). Analysis of Variance (ANOVA) indicated the mean time to ROSC for HIO and IV was 621.20 seconds (SD=204.21 seconds) and 554.50 seconds (SD=213.96 seconds), respectively, with no significant difference between the groups (U=11; P=.22). Multivariate Analysis of Variance (MANOVA) revealed the maximum plasma concentration (Cmax) and time to maximum concentration (Tmax) of vasopressin in the HIO and IV groups was 71753.9 pg/mL (SD=26744.58 pg/mL) and 61853.7 pg/mL (SD=22745.04 pg/mL); 111.42 seconds (SD=51.3 seconds) and 114.55 seconds (SD=55.02 seconds), respectively. Repeated measures ANOVA indicated no significant difference in plasma vasopressin concentrations between the treatment groups over four minutes (P=.48). CONCLUSIONS The HIO route delivered vasopressin effectively in a swine model of VF. Occurrence, time, and odds of ROSC, as well as pharmacokinetic measurements of HIO vasopressin, were comparable to IV. Burgert JM , Johnson AD , Garcia-Blanco J , Fulton LV , Loughren MJ . The resuscitative and pharmacokinetic effects of humeral intraosseous vasopressin in a swine model of ventricular fibrillation. Prehosp Disaster Med. 2017;32(3):305-310.
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Afzali M, Kvisselgaard AD, Lyngeraa TS, Viggers S. Intraosseous access can be taught to medical students using the four-step approach. BMC MEDICAL EDUCATION 2017; 17:50. [PMID: 28253870 PMCID: PMC5335802 DOI: 10.1186/s12909-017-0882-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 02/07/2017] [Indexed: 06/06/2023]
Abstract
BACKGROUND The intraosseous (IO) access is an alternative route for vascular access when peripheral intravascular catheterization cannot be obtained. In Denmark the IO access is reported as infrequently trained and used. The aim of this pilot study was to investigate if medical students can obtain competencies in IO access when taught by a modified Walker and Peyton's four-step approach. METHODS Nineteen students attended a human cadaver course in emergency procedures. A lecture was followed by a workshop. Fifteen students were presented with a case where IO access was indicated and their performance was evaluated by an objective structured clinical examination (OSCE) and rated using a weighted checklist. To evaluate the validity of the checklist, three raters rated performance and Cohen's kappa was performed to assess inter-rater reliability (IRR). To examine the strength of the overall IRR, Randolph's free-marginal multi rater kappa was used. RESULTS A maximum score of 15 points was obtained by nine (60%) of the participants and two participants (13%) scored 13 points with all three raters. Only one participant failed more than one item on the checklist. The expert rater rated lower with a mean score of 14.2 versus the non-expert raters with mean 14.6 and 14.3. The overall IRR calculated with Randolph's free-marginal multi rater kappa was 0.71. CONCLUSION The essentials of the IO access procedure can be taught to medical students using a modified version of the Walker and Peyton's four-step approach and the checklist used was found reliable.
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Affiliation(s)
- Monika Afzali
- Department of Anaesthesiology, University Hospital of Copenhagen, Herlev, Denmark
- Cochrane Anaesthesia, Critical and Emergency Care, The Cochrane Collaboration, Herlev, Denmark
| | - Ask Daffy Kvisselgaard
- Students’ Society of Anaesthesiology & Traumatology, Faculty of Health and Medical Sciences, University of Copenhagen, Herlev, Denmark
| | | | - Sandra Viggers
- Copenhagen Academy for Medical Education and Simulation, Capital Region of Denmark, Herlev, Denmark
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Blueprint for Implementing New Processes in Acute Care: Rescuing Adult Patients With Intraosseous Access. J Trauma Nurs 2017; 22:266-73. [PMID: 26352658 DOI: 10.1097/jtn.0000000000000152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The intraosseous (IO) access initiative at an urban university adult level 1 trauma center began from the need for a more expeditious vascular access route to rescue patients in extremis. The goal of this project was a multidisciplinary approach to problem solving to increase access of IO catheters to rescue patients in all care areas. The initiative became a collaborative effort between nursing, physicians, and pharmacy to embark on an acute care endeavor to standardize IO access. This is a descriptive analysis of processes to effectively develop collaborative strategies to navigate hospital systems and successfully implement multilayered initiatives. Administration should empower nurse to advance their practice to include IO for patient rescue. Intraosseous access may expedite resuscitative efforts in patients in extremis who lack venous access or where additional venous access is required for life-saving therapies. Limiting IO dwell time may facilitate timely definitive venous access. Continued education and training by offering IO skill laboratory refreshers and annual e-learning didactic is optimal for maintaining proficiency and knowledge. More research opportunities exist to determine medication safety and efficacy in adult patients in the acute care setting.
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Engels PT, Erdogan M, Widder SL, Butler MB, Kureshi N, Martin K, Green RS. Use of intraosseous devices in trauma: a survey of trauma practitioners in Canada, Australia and New Zealand. Can J Surg 2016; 59:374-382. [PMID: 27669404 PMCID: PMC5125919 DOI: 10.1503/cjs.011215] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 06/20/2016] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Although used primarily in the pediatric population for decades, the use of intraosseous (IO) devices in the resuscitation of severely injured adult trauma patients has recently become more commonplace. The objective of this study was to determine the experience level, beliefs and attitudes of trauma practitioners in Canada, Australia and New Zealand regarding the use of IO devices in adult trauma patients. METHODS We administered a web-based survey to all members of 4 national trauma and emergency medicine organizations in Canada, Australia and New Zealand. Survey responses were analyzed using descriptive statistics, univariate comparisons and a proportional odds model. RESULTS Overall, 425 of 1771 members completed the survey, with 375 being trauma practitioners. IO devices were available to 97% (353 of 363), with EZ-IO being the most common. Nearly all physicians (98%, 357 of 366) had previous training with IO devices, and 85% (223 of 261) had previously used an IO device in adult trauma patients. Most respondents (79%, 285 of 361) were very comfortable placing an IO catheter in the proximal tibia. Most physicians would always or often use an IO catheter in a patient without intravenous access undergoing CPR for traumatic cardiac arrest (84%, 274 of 326) or in a hypotensive patient (without peripheral intravenous access) after 2 attempts or 90 s of trying to establish vascular access (81%, 264 of 326). CONCLUSION Intraosseous devices are readily available to trauma practitioners in Canada, Australia and New Zealand, and most physicians are trained in device placement. Most physicians surveyed felt comfortable using an IO device in resuscitation of adult trauma patients and would do so for indications broader than current guidelines.
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Affiliation(s)
- Paul T. Engels
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Engels); Trauma Nova Scotia, Halifax, NS (Erdogan, Green); the Department of Surgery, University of Alberta, Edmonton, Alta. (Widder); the Department of Critical Care Medicine, Dalhousie University, Halifax, NS (Butler, Kureshi, Green); and the Alfred Hospital, Melbourne, Australia (Martin)
| | - Mete Erdogan
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Engels); Trauma Nova Scotia, Halifax, NS (Erdogan, Green); the Department of Surgery, University of Alberta, Edmonton, Alta. (Widder); the Department of Critical Care Medicine, Dalhousie University, Halifax, NS (Butler, Kureshi, Green); and the Alfred Hospital, Melbourne, Australia (Martin)
| | - Sandy L. Widder
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Engels); Trauma Nova Scotia, Halifax, NS (Erdogan, Green); the Department of Surgery, University of Alberta, Edmonton, Alta. (Widder); the Department of Critical Care Medicine, Dalhousie University, Halifax, NS (Butler, Kureshi, Green); and the Alfred Hospital, Melbourne, Australia (Martin)
| | - Michael B. Butler
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Engels); Trauma Nova Scotia, Halifax, NS (Erdogan, Green); the Department of Surgery, University of Alberta, Edmonton, Alta. (Widder); the Department of Critical Care Medicine, Dalhousie University, Halifax, NS (Butler, Kureshi, Green); and the Alfred Hospital, Melbourne, Australia (Martin)
| | - Nelofar Kureshi
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Engels); Trauma Nova Scotia, Halifax, NS (Erdogan, Green); the Department of Surgery, University of Alberta, Edmonton, Alta. (Widder); the Department of Critical Care Medicine, Dalhousie University, Halifax, NS (Butler, Kureshi, Green); and the Alfred Hospital, Melbourne, Australia (Martin)
| | - Kate Martin
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Engels); Trauma Nova Scotia, Halifax, NS (Erdogan, Green); the Department of Surgery, University of Alberta, Edmonton, Alta. (Widder); the Department of Critical Care Medicine, Dalhousie University, Halifax, NS (Butler, Kureshi, Green); and the Alfred Hospital, Melbourne, Australia (Martin)
| | - Robert S. Green
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Engels); Trauma Nova Scotia, Halifax, NS (Erdogan, Green); the Department of Surgery, University of Alberta, Edmonton, Alta. (Widder); the Department of Critical Care Medicine, Dalhousie University, Halifax, NS (Butler, Kureshi, Green); and the Alfred Hospital, Melbourne, Australia (Martin)
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Zhang W, Liu C, Hai B, Du G, Wang H, Leng H, Xu Y, Song C. A Convenient In Vivo Model Using Small Interfering RNA Silencing to Rapidly Assess Skeletal Gene Function. PLoS One 2016; 11:e0167222. [PMID: 27893850 PMCID: PMC5125699 DOI: 10.1371/journal.pone.0167222] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 11/10/2016] [Indexed: 12/15/2022] Open
Abstract
It is difficult to study bone in vitro because it contains various cell types that engage in cross-talk. Bone biologically links various organs, and it has thus become increasingly evident that skeletal physiology must be studied in an integrative manner in an intact animal. We developed a model using local intraosseous small interfering RNA (siRNA) injection to rapidly assess the effects of a target gene on the local skeletal environment. In this model, 160-g male Sprague-Dawley rats were treated for 1-2 weeks. The left tibia received intraosseous injection of a parathyroid hormone 1 receptor (Pth1r) or insulin-like growth factor 1 receptor (Igf-1r) siRNA transfection complex loaded in poloxamer 407 hydrogel, and the right tibia received the same volume of control siRNA. All the tibias received an intraosseous injection of recombinant human parathyroid hormone (1-34) (rhPTH (1-34)) or insulin-like growth factor-1 (IGF-1). Calcein green and alizarin red were injected 6 and 2 days before euthanasia, respectively. IGF-1R and PTH1R expression levels were detected via RT-PCR assays and immunohistochemistry. Bone mineral density (BMD), microstructure, mineral apposition rates (MARs), and strength were determined by dual-energy X-ray absorptiometry, micro-CT, histology and biomechanical tests. The RT-PCR and immunohistochemistry results revealed that IGF-1R and PTH1R expression levels were dramatically diminished in the siRNA-treated left tibias compared to the right tibias (both p<0.05). Using poloxamer 407 hydrogel as a controlled-release system prolonged the silencing effect of a single dose of siRNA; the mRNA expression levels of IGF-1R were lower at two weeks than at one week (p<0.01). The BMD, bone microstructure parameters, MAR and bone strength were significantly decreased in the left tibias compared to the right tibias (all p<0.05). This simple and convenient local intraosseous siRNA injection model achieved gene silencing with very small quantities of siRNA over a short treatment period (≤7 days).
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Affiliation(s)
- Wen Zhang
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Spinal Diseases, Beijing, China
| | - Can Liu
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Spinal Diseases, Beijing, China
| | - Bao Hai
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Spinal Diseases, Beijing, China
| | - Guohong Du
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Hong Wang
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Spinal Diseases, Beijing, China
| | - Huijie Leng
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Spinal Diseases, Beijing, China
| | - Yingsheng Xu
- Department of Neurology, Peking University Third Hospital, Beijing, China
| | - Chunli Song
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
- Beijing Key Laboratory of Spinal Diseases, Beijing, China
- * E-mail:
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Fu X, Tan J, Sun CG, Leng HJ, Xu YS, Song CL. Intraosseous Injection of Simvastatin in Poloxamer 407 Hydrogel Improves Pedicle-Screw Fixation in Ovariectomized Minipigs. J Bone Joint Surg Am 2016; 98:1924-1932. [PMID: 27852910 DOI: 10.2106/jbjs.15.00937] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Osteoporosis leads to poor osseointegration and reduces implant stability. Statins have been found to stimulate bone formation, but the bioavailability from oral administration is low. Local application may be more effective at augmenting bone formation and enhancing implant stability. This study was performed to evaluate the efficacy of an intraosseous injection of simvastatin in thermosensitive poloxamer 407 hydrogel to enhance pedicle-screw fixation in calcium-restricted ovariectomized minipigs. METHODS Nine mature female Guangxi Bama minipigs underwent bilateral ovariectomy and were fed a calcium-restricted diet for 18 months. Simvastatin (0, 0.5, or 1 mg) in thermosensitive poloxamer 407 hydrogel was injected into the lumbar vertebrae (L4-L6), and titanium alloy pedicle screws were implanted. Bone mineral density (BMD) measurements of the lumbar vertebrae were determined by dual x-ray absorptiometry (DXA) before and 3 months after treatment. The lumbar vertebrae were harvested and analyzed with use of microcomputed tomography, biomechanical pull-out testing, histological analysis, and Western blot analysis for bone morphogenetic protein (BMP)-2 and vascular endothelial growth factor (VEGF) expression. RESULTS Evaluation over a 3-month study period demonstrated that the BMD of the vertebrae injected with 0.5 and 1.0 mg of simvastatin had increased by 31.25% and 31.09%, respectively, compared with vehicle-only injection (p ≤ 0.00014 for both) and increased by 32.12% and 28.16%, respectively, compared with the pre-treatment levels (p < 0.0001 for both). A single injection of simvastatin in poloxamer 407 increased trabecular volume fraction, thickness, and number and decreased trabecular separation (p ≤ 0.002). The bone formation and mineral apposition rates significantly increased (p ≤ 0.023). The percentage of osseointegration in the simvastatin 0.5 and 1-mg groups was 46.54% and 42.63% greater, respectively, than that in the vehicle-only group (p ≤ 0.006), and the maximum pull-out strength was 45.75% and 51.53% greater, respectively, than in the vehicle-only group (p ≤ 0.0005). BMP-2 and VEGF expressions were higher than for the vehicle-only injection. CONCLUSIONS A single intraosseous injection of simvastatin in thermosensitive poloxamer 407 hydrogel stimulated bone formation, increased BMD, improved bone microstructure, promoted osseointegration, and significantly enhanced the stability of pedicle screws in calcium-restricted ovariectomized minipigs. CLINICAL RELEVANCE These results provide rationale for evaluating intraosseous injection of simvastatin in poloxamer 407 to enhance implant fixation in patients with osteoporosis.
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Affiliation(s)
- X Fu
- Departments of Orthopedics (X.F., J.T., C.G.S., H.J.L., and C.L.S.) and Neurology (Y.S.X.), Peking University Third Hospital, Beijing, People's Republic of China
| | - J Tan
- Departments of Orthopedics (X.F., J.T., C.G.S., H.J.L., and C.L.S.) and Neurology (Y.S.X.), Peking University Third Hospital, Beijing, People's Republic of China
| | - C G Sun
- Departments of Orthopedics (X.F., J.T., C.G.S., H.J.L., and C.L.S.) and Neurology (Y.S.X.), Peking University Third Hospital, Beijing, People's Republic of China.,Beijing Key Laboratory of Spinal Diseases, Beijing, People's Republic of China
| | - H J Leng
- Departments of Orthopedics (X.F., J.T., C.G.S., H.J.L., and C.L.S.) and Neurology (Y.S.X.), Peking University Third Hospital, Beijing, People's Republic of China.,Beijing Key Laboratory of Spinal Diseases, Beijing, People's Republic of China
| | - Y S Xu
- Departments of Orthopedics (X.F., J.T., C.G.S., H.J.L., and C.L.S.) and Neurology (Y.S.X.), Peking University Third Hospital, Beijing, People's Republic of China
| | - C L Song
- Departments of Orthopedics (X.F., J.T., C.G.S., H.J.L., and C.L.S.) and Neurology (Y.S.X.), Peking University Third Hospital, Beijing, People's Republic of China .,Beijing Key Laboratory of Spinal Diseases, Beijing, People's Republic of China
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Boysen SR, Pang JM, Mikler JR, Knight CG, Semple HA, Caulkett NA. Comparison of tranexamic acid plasma concentrations when administered via intraosseous and intravenous routes. Am J Emerg Med 2016; 35:227-233. [PMID: 27816438 DOI: 10.1016/j.ajem.2016.10.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 10/18/2016] [Accepted: 10/22/2016] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION There is a lack of information regarding intraosseous (IO) administration of tranexamic acid (TXA). Our hypothesis was that a single bolus IO injection of TXA will have a similar pharmacokinetic profile to TXA administered at the same dose IV. METHODS Sixteen male Landrace cross swine (mean body weight 27.6±2.6kg) were divided into an IV group (n=8) and an IO group (n=8). Each animal received 30mg/kg TXA via an IV or IO catheter, respectively. Jugular blood samples were collected for pharmacokinetic analysis over a 3h period. The maximum TXA plasma concentration (Cmax) and corresponding time as well as distribution half-life, elimination half-life, area under the curve, plasma clearance and volume of distribution were calculated. One- and two-way analysis of variance for repeated measures (time, group) with Tukey's and Bonferonni post hoc tests were used to compare TXA plasma concentrations within and between groups, respectively. RESULTS Plasma concentrations of TXA were significantly higher (p<0.0001) in the IV group during the TXA infusion. Cmax occurred at 4min after initiation of the bolus in the IV group (9.36±3.20ng/μl) and at 5min after initiation of the bolus in the IO group (4.46±0.49ng/μl). Plasma concentrations were very similar from the completion of injection onwards. There were no significant differences between the two administration routes for any other pharmacokinetic variables measured. CONCLUSION The results of this study support pharmacokinetic bioequivalence of IO and IV administration of TXA.
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Affiliation(s)
- Søren R Boysen
- Department of Veterinary Clinical and Diagnostic Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada.
| | - Jessica M Pang
- Department of Veterinary Clinical and Diagnostic Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
| | - John R Mikler
- Defence Research and Development Canada - Suffield Research Centre, Box 4000, Station Main, Medicine Hat, Alberta T1A 8K6, Canada
| | - Cameron G Knight
- Department of Veterinary Clinical and Diagnostic Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
| | - Hugh A Semple
- Defence Research and Development Canada - Suffield Research Centre, Box 4000, Station Main, Medicine Hat, Alberta T1A 8K6, Canada
| | - Nigel A Caulkett
- Department of Veterinary Clinical and Diagnostic Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
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Aktuelle Empfehlungen zum Basic/Advanced Life Support. Med Klin Intensivmed Notfmed 2016; 111:670-681. [DOI: 10.1007/s00063-016-0216-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 08/10/2016] [Accepted: 08/23/2016] [Indexed: 10/20/2022]
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Soar J, Nolan JP, Böttiger BW, Perkins GD, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars MB, Smith GB, Sunde K, Deakin CD. European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation 2016; 95:100-47. [PMID: 26477701 DOI: 10.1016/j.resuscitation.2015.07.016] [Citation(s) in RCA: 923] [Impact Index Per Article: 115.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Germany
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
| | - Pierre Carli
- SAMU de Paris, Department of Anaesthesiology and Intensive Care, Necker University Hospital, Paris, France
| | - Tommaso Pellis
- Anaesthesia, Intensive Care and Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | - Markus B Skrifvars
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Gary B Smith
- Centre of Postgraduate Medical Research & Education, Bournemouth University, Bournemouth, UK
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, UK
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Wolfson DL, Tandoh MA, Jindal M, Forgione PM, Harder VS. Adult Intraosseous Access by Advanced EMTs: A Statewide Non-Inferiority Study. PREHOSP EMERG CARE 2016; 21:7-13. [DOI: 10.1080/10903127.2016.1209262] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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A Comparison of the Effects of Intraosseous and Intravenous 5% Albumin on Infusion Time and Hemodynamic Measures in a Swine Model of Hemorrhagic Shock. Prehosp Disaster Med 2016; 31:436-42. [PMID: 27210025 DOI: 10.1017/s1049023x16000509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
UNLABELLED Introduction Obtaining intravenous (IV) access in patients in hemorrhagic shock is often difficult and prolonged. Failed IV attempts delay life-saving treatment. Intraosseous (IO) access may often be obtained faster than IV access. Albumin (5%) is an option for prehospital volume expansion because of the absence of interference with coagulation and platelet function. Hypothesis/Problem There are limited data comparing the performance of IO and IV administered 5% albumin. The aims of this study were to compare the effects of tibial IO (TIO) and IV administration of 500 mL of 5% albumin on infusion time and hemodynamic measurements of heart rate (HR), mean arterial pressure (MAP), cardiac output (CO), and stroke volume (SV) in a swine model of hemorrhagic shock. METHODS Sixteen male swine were divided into two groups: TIO and IV. All subjects were anesthetized and a Class III hemorrhage was achieved by exsanguination of 31% of estimated blood volume (EBV) from a femoral artery catheter. Following exsanguination, 500 mL of 5% albumin was administered under pressurized infusion (300 mmHg) by the TIO or IV route and infusion time was recorded. Hemodynamic measurements of HR, MAP, CO, and SV were collected before and after exsanguination and every 20 seconds for 180 seconds during 5% albumin infusion. RESULTS An independent t-test determined that IV 5% albumin infusion was significantly faster compared to IO (P=.01). Mean infusion time for TIO was seven minutes 35 seconds (SD=two minutes 44 seconds) compared to four minutes 32 seconds (SD=one minute 08 seconds) in the IV group. Multivariate Analysis of Variance was performed on hemodynamic data collected during the 5% albumin infusion. Analyses indicated there were no significant differences between the TIO and IV groups relative to MAP, CO, HR, or SV (P>.05). CONCLUSION While significantly longer to infuse 5% albumin by the TIO route, the longer TIO infusion time may be negated as IO devices can be placed more quickly compared to repeated IV attempts. The lack of significant difference between the TIO and IV routes relative to hemodynamic measures indicate the TIO route is a viable route for the infusion of 5% albumin in a swine model of Class III hemorrhage. Muir SL , Sheppard LB , Maika-Wilson A , Burgert JM , Garcia-Blanco J , Johnson AD , Coyner JL . A comparison of the effects of intraosseous and intravenous 5% albumin on infusion time and hemodynamic measures in a swine model of hemorrhagic shock. Prehosp Disaster Med. 2016;31(4):436-442.
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