Intravenous vs. intraosseous administration of drugs during cardiac arrest: A systematic review

Re-evaluating intra-cardiac arrest adjunctive medications and routes of drug administration

PURPOSE OF REVIEW

This narrative review summarizes the evidence for the most commonly used intra-cardiac arrest adjunctive medications and routes of administration and discusses promising new therapies from preclinical animal models.

RECENT FINDINGS

Large trials on the administration of calcium as well as the combination of vasopressin and glucocorticoids during cardiac arrest have been published. Calcium administration during cardiopulmonary resuscitation does not improve outcomes and might cause harm. Vasopressin and glucocorticoid administration during cardiopulmonary resuscitation improve the chance of return of spontaneous circulation but has uncertain effects on survival. We identified a total of seven ongoing clinical trials investigating the potential role of bicarbonate, of vasopressin and glucocorticoids, and of intravenous versus intraosseous vascular access. Several medications such as levosimendan and inhaled nitric oxide show promise in preclinical studies, and clinical trials are either planned or actively recruiting.

SUMMARY

Large trials on intra-cardiac arrest administration of calcium and vasopressin with glucocorticoids have been performed. Several trials are ongoing that will provide valuable insights into the potential benefit of other intra-cardiac arrest medications such as bicarbonate as well as the potential benefit of intravenous or intraosseous vascular access.

Intraosseous and Intravenous Epinephrine Administration Routes in Out-of-Hospital Cardiac Arrest: Survival and Neurologic Outcomes

BACKGROUND

The rate of survival after out-of-hospital cardiac arrest varies depending on the timeliness and effectiveness of prehospital interventions. This study was conducted to compare out-of-hospital cardiac arrest outcomes between intravenous and intraosseous routes and between upper and lower extremity routes for drug administration.

METHODS AND RESULTS

We retrospectively analyzed data (collected using the Utstein template) from 1220 patients who had experienced out-of-hospital cardiac arrest in Taiwan's Taoyuan City between January 2021 and August 2023. The patients were stratified into intravenous and intraosseous groups by treatment approach and upper and lower extremity access groups by access site. The study outcomes were survival to discharge, favorable neurologic outcomes (Cerebral Performance Category score 1 or 2), and survival for >2 hours. The study groups were statistically compared before and after propensity score matching. Significant pre-propensity score matching differences were observed between intravenous and intraosseous groups, and the aforementioned study outcomes were better in the intravenous group than in the intraosseous group. However, the between-group differences became nonsignificant after propensity score matching. Furthermore, lower extremity access and delayed epinephrine administration were associated with worse outcomes. Survival rates fell below 12.6% when time to treatment exceeded 15 minutes, particularly in the cases of intraosseous access and lower extremity access.

CONCLUSIONS

This study highlights the benefits of early intervention and upper extremity access for drug administration in patients with out-of-hospital cardiac arrest. Intraosseous access may serve as a viable alternative to intravenous access. Timely administration of essential drugs during resuscitation can improve clinical outcomes and thus has implications for emergency medical service training.

Intraosseous or Intravenous Vascular Access for Out-of-Hospital Cardiac Arrest

BACKGROUND

Out-of-hospital cardiac arrest is a leading cause of death worldwide. Establishing vascular access is critical for administering guideline-recommended drugs during cardiopulmonary resuscitation. Both the intraosseous route and the intravenous route are used routinely, but their comparative effectiveness remains unclear.

METHODS

We conducted a randomized clinical trial to compare the effectiveness of initial attempts at intraosseous or intravenous vascular access in adults who had nontraumatic out-of-hospital cardiac arrest. The primary outcome was a sustained return of spontaneous circulation. Key secondary outcomes were survival at 30 days and survival at 30 days with a favorable neurologic outcome, defined by a score of 0 to 3 on the modified Rankin scale (scores range from 0 to 6, with higher scores indicating greater disability).

RESULTS

Among 1506 patients who underwent randomization, 1479 were included in the primary analysis (731 in the intraosseous-access group and 748 in the intravenous-access group). The successful establishment of vascular access within two attempts occurred in 669 patients (92%) assigned to the intraosseous-access group and in 595 patients (80%) assigned to the intravenous-access group. Sustained return of spontaneous circulation occurred in 221 patients (30%) in the intraosseous-access group and in 214 patients (29%) in the intravenous-access group (risk ratio, 1.06; 95% confidence interval [CI], 0.90 to 1.24; P = 0.49). At 30 days, 85 patients (12%) in the intraosseous-access group and 75 patients (10%) in the intravenous-access group were alive (risk ratio, 1.16; 95% CI, 0.87 to 1.56); a favorable neurologic outcome at 30 days occurred in 67 patients (9%) and 59 patients (8%), respectively (risk ratio, 1.16; 95% CI, 0.83 to 1.62). Prespecified adverse events were uncommon.

CONCLUSIONS

There was no significant difference in sustained return of spontaneous circulation between initial intraosseous and intravenous vascular access in adults who had out-of-hospital cardiac arrest. (Funded by the Novo Nordisk Foundation and others; IVIO EU Clinical Trials Register number, 2022-500744-38-00; ClinicalTrials.gov number, NCT05205031.).

A Randomized Trial of Drug Route in Out-of-Hospital Cardiac Arrest

BACKGROUND

In patients with out-of-hospital cardiac arrest, the effectiveness of drugs such as epinephrine is highly time-dependent. An intraosseous route of drug administration may enable more rapid drug administration than an intravenous route; however, its effect on clinical outcomes is uncertain.

METHODS

We conducted a multicenter, open-label, randomized trial across 11 emergency medical systems in the United Kingdom that involved adults in cardiac arrest for whom vascular access for drug administration was needed. Patients were randomly assigned to receive treatment from paramedics by means of an intraosseous-first or intravenous-first vascular access strategy. The primary outcome was survival at 30 days. Key secondary outcomes included any return of spontaneous circulation and favorable neurologic function at hospital discharge (defined by a score of 3 or less on the modified Rankin scale, on which scores range from 0 to 6, with higher scores indicating greater disability). No adjustment for multiplicity was made.

RESULTS

A total of 6082 patients were assigned to a trial group: 3040 to the intraosseous group and 3042 to the intravenous group. At 30 days, 137 of 3030 patients (4.5%) in the intraosseous group and 155 of 3034 (5.1%) in the intravenous group were alive (adjusted odds ratio, 0.94; 95% confidence interval [CI], 0.68 to 1.32; P = 0.74). At the time of hospital discharge, a favorable neurologic outcome was observed in 80 of 2994 patients (2.7%) in the intraosseous group and in 85 of 2986 (2.8%) in the intravenous group (adjusted odds ratio, 0.91; 95% CI, 0.57 to 1.47); a return of spontaneous circulation at any time occurred in 1092 of 3031 patients (36.0%) and in 1186 of 3035 patients (39.1%), respectively (adjusted odds ratio, 0.86; 95% CI, 0.76 to 0.97). During the trial, one adverse event, which occurred in the intraosseous group, was reported.

CONCLUSIONS

Among adults with out-of-hospital cardiac arrest requiring drug therapy, the use of an intraosseous-first vascular access strategy did not result in higher 30-day survival than an intravenous-first strategy. (Funded by the National Institute for Health and Care Research; PARAMEDIC-3 ISRCTN Registry number, ISRCTN14223494.).

Management of Patients With Cardiac Arrest Requiring Interfacility Transport: A Scientific Statement From the American Heart Association

People who experience out-of-hospital cardiac arrest often require care at a regional center for continued treatment after resuscitation, but many do not initially present to the hospital where they will be admitted. For patients who require interfacility transport after cardiac arrest, the decision to transfer between centers is complex and often based on individual clinical characteristics, resources at the presenting hospital, and available transport resources. Once the decision has been made to transfer a patient after cardiac arrest, there is little direct guidance on how best to provide interfacility transport. Accepting centers depend on transferring emergency departments and emergency medical services professionals to make important and nuanced decisions about postresuscitation care that may determine the efficacy of future treatments. The consequences of early care are greater when transport delays occur, which is common in rural areas or due to inclement weather. Challenges of providing interfacility transfer services for patients who have experienced cardiac arrest include varying expertise of clinicians, differing resources available to them, and nonstandardized communication between transferring and receiving centers. Although many aspects of care are insufficiently studied to determine implications for specific out-of-hospital treatment on outcomes, a general approach of maintaining otherwise recommended postresuscitation care during interfacility transfer is reasonable. This includes close attention to airway, vascular access, ventilator management, sedation, cardiopulmonary monitoring, antiarrhythmic treatments, blood pressure control, temperature control, and metabolic management. Patient stability for transfer, equity and inclusion, and communication also must be considered. Many of these aspects can be delivered by protocol-driven care.

The Route to ROSC: Evaluating the Impact of Route and Timing of Epinephrine Administration in Out-of-Hospital Cardiac Arrest Outcomes

OBJECTIVES

Previous investigations comparing intraosseous (IO) and intravenous (IV) epinephrine delivery in out-of-hospital cardiac arrest (OHCA) suggest that epinephrine is oftentimes more expeditiously administered via the IO route, but this temporal benefit doesn't always translate to clinical benefit. However, very few studies adequately controlled for indication and resuscitation time biases, making the influence of first epinephrine route on OHCA outcomes unclear. To determine the association between first epinephrine route and return of spontaneous circulation (ROSC) while controlling for resuscitation time bias and other potential confounders.

METHODS

We conducted a retrospective analysis using the 2020 ESO Data Collaborative dataset. Adult patients with a witnessed, non-traumatic OHCA prior to EMS arrival were included. Logistic regression was used to determine the association between medication route and ROSC. Linear regression was then used to calculate the probability of ROSC for each route across all call receipt-to-drug delivery intervals. Using these linear equations, the call receipt-to-drug delivery intervals were calculated that would yield equivalent probabilities of ROSC between the IV and IO routes.

RESULTS

Data were available for 10,350 patients, of which 27.4% presented with a shockable rhythm, 29.7% received bystander CPR, and 39.6% experienced ROSC. After controlling for confounders, IO epinephrine was associated with decreased likelihood of ROSC (OR = 0.77, p < 0.001). The linear regression models provided differing slope coefficients for ROSC between each route, with the IV route associated with a higher likelihood of ROSC for any given call receipt-to-drug-delivery interval. From these equations, the additional time allowed to establish an IV and administer epinephrine intravenously beyond the time required for IO delivery, yet with an equivalent predicted probability of ROSC via the IO route, was calculated. This additional time interval for intravenous administration declined linearly from 9 min at a call receipt-to-intraosseous epinephrine interval of 4 min to no additional time at a call receipt-to-intraosseous epinephrine interval of 29 min.

CONCLUSIONS

This retrospective analysis of a national EMS database revealed that IO epinephrine was negatively associated with ROSC. Additionally, there appears to be a finite time window during which intravenous epinephrine remains superior to the intraosseous route even if there are brief initial delays in IV drug delivery.

The association of intravenous vs. humeral-intraosseous vascular access with patient outcomes in adult out-of-hospital cardiac arrests

AIM

While intravenous (IV) vascular access for out-of-hospital cardiac arrest (OHCA) resuscitation is standard, humeral-intraosseous (IO) access is commonly used, despite few supporting data. We investigated the association between IV vs. humeral-IO and outcomes.

METHODS

We utilized BC Cardiac Arrest Registry data, including adult OHCA where the first-attempted intra-arrest vascular access route performed by advanced life support (ALS)-trained paramedics was IV or humeral-IO. We fit a propensity-score adjusted model with inverse probability treatment weighting to estimate the association between IV vs. humeral-IO routes and favorable neurological outcomes (CPC 1-2) and survival at hospital discharge. We repeated models within subgroups defined by initial cardiac rhythm.

RESULTS

We included 2,112 cases; the first-attempted route was IV (n = 1,575) or humeral-IO (n = 537). Time intervals from ALS-paramedic on-scene arrival to vascular access (6.6 vs. 6.9 min) and epinephrine administration (9.0 vs. 9.3 min) were similar between IV and IO groups, respectively. Among IV and humeral-IO groups, 98 (6.2%) and 20 (3.7%) had favorable neurological outcomes. Compared to humeral-IO, an IV-first approach was associated with improved hospital-discharge favorable neurological outcomes (AOR 1.7; 95% CI 1.1-2.7) and survival (AOR 1.5; 95% CI 1.0-2.3). Among shockable rhythm cases, an IV-first approach was associated with improved favorable neurological outcomes (AOR 4.2; 95% CI 2.1-8.2), but not among non-shockable rhythm cases (AOR 0.73; 95% CI 0.39-1.4).

CONCLUSION

An IV-first approach, compared to humeral-IO, for intra-arrest resuscitation was associated with an improved odds of favorable neurological outcomes and survival to hospital discharge. This association was seen among an initial shockable rhythm, but not non-shockable rhythm, subgroups.

Intraosseous versus intravenous vascular access in upper extremity among adults with out-of-hospital cardiac arrest: cluster randomised clinical trial (VICTOR trial)

OBJECTIVE

To compare the effectiveness of intraosseous versus intravenous vascular access in the treatment of adult patients with out-of-hospital cardiac arrest.

DESIGN

Cluster randomised controlled trial.

SETTING

The VICTOR (Venous Injection Compared To intraOsseous injection during resuscitation of patients with out-of-hospital cardiac arrest) trial involved emergency medical service agencies with all four advanced life support ambulance teams in Taipei City, Taiwan. The enrolment period spanned 6 July 2020 to 30 June 2023 and was temporarily suspended between 20 May 2021 and 31 July 2021 owing to the covid-19 pandemic.

PARTICIPANTS

Adult (age 20-80 years) patients with non-traumatic out-of-hospital cardiac arrest.

INTERVENTIONS

Biweekly randomised clusters of four participating advanced life support ambulance teams were assigned to insert either intravenous or intraosseous access.

MAIN OUTCOME MEASURES

The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation, sustained return of spontaneous circulation (≥2 hours), and survival with favourable neurological outcomes (cerebral performance category score ≤2) at hospital discharge.

RESULTS

Among 1771 enrolled patients, 1732 (741 in the intraosseous group and 991 in the intravenous group) were included in the primary analysis (median age 65.0 years; 1234 (71.2%) men). In the intraosseous group, 79 (10.7%) patients were discharged alive, compared with 102 (10.3%) patients in the intravenous group (odds ratio 1.04, 95% confidence interval 0.76 to 1.42; P=0.81). The odds ratio of intraosseous versus intravenous access was 1.23 (0.89 to 1.69; P=0.21) for pre-hospital return of spontaneous circulation, 0.92 (0.75 to 1.13; P=0.44) for sustained return of spontaneous circulation, and 1.17 (0.82 to 1.66; P=0.39) for survival with favourable neurological outcomes.

CONCLUSIONS

Among adults with non-traumatic out-of-hospital cardiac arrest, initial attempts to establish vascular access through the intraosseous route did not result in different outcomes compared with intravenous access in terms of the proportion of patients surviving to hospital discharge, pre-hospital return of spontaneous circulation, sustained return of spontaneous circulation, and favourable neurological outcomes.

TRIAL REGISTRATION

NCT04135547ClinicalTrials.gov NCT04135547.

Systematic overview of intraosseous access versus intravenous delivery for emergency resuscitation: Efficacy and quality of existing evidence

BACKGROUND

The impact of intraosseous (IO) access on resuscitation outcomes, as compared to intravenous (IV) administration, is subject to ongoing debate. This review aims to provide a comprehensive evaluation of the methodological, reporting, and evidence quality of existing Systematic Reviews/Meta-Analyses (SRs/MAs) on IO use during resuscitation.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a strategic literature search to identify pertinent SRs/MAs published up until May 6th, 2023. After an extensive screening process, 4 SRs/MAs were included for review. We used the A Measurement Tool to Assess Systematic Reviews-2 tool for assessing methodological quality, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist for evaluating reporting quality, and the Grading of Recommendations Assessment, Development, and Evaluation framework for examining the quality of evidence.

RESULTS

The assessment revealed high methodological quality across all the included SRs/MAs but showed significant variability in the quality of evidence. The studies offered conflicting findings on the impact of IO access on resuscitation outcomes such as return of spontaneous circulation, survival rates at hospital discharge, and favorable neurological outcomes. Some studies suggested an association of IO access with poorer outcomes, while others indicated no significant difference between IO and IV routes.

CONCLUSIONS

Despite the perceived utility of IO access when IV access is unachievable, the impact of IO on survival, return of spontaneous circulation, and neurological outcomes remains ambiguous due to the inconsistency in the existing evidence. This review underscores the critical need for more rigorous and consistent primary research in this area to strengthen clinical guidelines and improve patient outcomes.

Out-of-Hospital Cardiac Arrest

Survival from out-of-hospital cardiac arrest (OHCA) is predicated on a community and system-wide approach that includes rapid recognition of cardiac arrest, capable bystander CPR, effective basic and advanced life support (BLS and ALS) by EMS providers, and coordinated postresuscitation care. Management of these critically ill patients continues to evolve. This article focuses on the management of OHCA by EMS providers.

Intraosseous access in the resuscitation of patients with trauma: the good, the bad, the future

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.

Route of drug administration in out-of-hospital cardiac arrest: A protocol for a randomised controlled trial (PARAMEDIC-3)

Aims

The PARAMEDIC-3 trial evaluates the clinical and cost-effectiveness of an intraosseous first strategy, compared with an intravenous first strategy, for drug administration in adults who have sustained an out-of-hospital cardiac arrest.

Methods

PARAMEDIC-3 is a pragmatic, allocation concealed, open-label, multi-centre, superiority randomised controlled trial. It will recruit 15,000 patients across English and Welsh ambulance services. Adults who have sustained an out-of-hospital cardiac arrest are individually randomised to an intraosseous access first strategy or intravenous access first strategy in a 1:1 ratio through an opaque, sealed envelope system. The randomised allocation determines the route used for the first two attempts at vascular access. Participants are initially enrolled under a deferred consent model.The primary clinical-effectiveness outcome is survival at 30-days. Secondary outcomes include return of spontaneous circulation, neurological functional outcome, and health-related quality of life. Participants are followed-up to six-months following cardiac arrest. The primary health economic outcome is incremental cost per quality-adjusted life year gained.

Conclusion

The PARAMEDIC-3 trial will provide key information on the clinical and cost-effectiveness of drug route in out-of-hospital cardiac arrest.Trial registration: ISRCTN14223494, registered 16/08/2021, prospectively registered.

The association of tibial vs. humeral intraosseous vascular access with patient outcomes in adult out-of-hospital cardiac arrests

AIM

Humeral and tibial intraosseous (IO) vascular access can deliver resuscitative medications for out-of-hospital cardiac arrest (OHCA), however the optimal site is unclear. We examined the association between IO tibia vs. humerus as the first-attempted vascular access site with OHCA outcomes.

METHODS

We used prospectively-collected data from the British Columbia Cardiac Arrest registry, including adult OHCAs treated with IO humerus or IO tibia as the first-attempted intra-arrest vascular access. We fit logistic regression models on the full study cohort and a propensity-matched cohort, to estimate the association between IO site and both favorable neurological outcomes (Cerebral Performance Category 1-2) and survival at hospital discharge.

RESULTS

We included 1041 (43%) and 1404 (57%) OHCAs for whom IO humerus and tibia, respectively, were the first-attempted intra-arrest vascular access. Among humerus and tibia cases, 1010 (97%) and 1369 (98%) had first-attempt success, and the median paramedic arrival-to-successful access interval was 6.7 minutes (IQR 4.4-9.4) and 6.1 minutes (IQR 4.1-8.9), respectively. In the propensity-matched cohort (n = 2052), 31 (3.0%) and 44 (4.3%) cases had favourable neurological outcomes in the IO humerus and IO tibia groups, respectively; compared to IO humerus, we did not detect an association between IO tibia with favorable neurological outcomes (OR 1.44; 95% CI 0.90-2.29) or survival to hospital discharge (OR 1.29; 95% CI 0.83-2.01). Results using the full cohort were similar.

CONCLUSIONS

We did not detect an association between the first-attempted intra-arrest IO site (tibia vs. humerus) and clinical outcomes. Clinical trials are warranted to test differences between vascular access strategies.

Self-Efficacy in the Cannulation Technique for Intraosseous Access in Pediatric Cardiac Arrest: Egg Versus Bone

OBJECTIVES

The use of intraosseous (IO) access is recommended in cardiac arrest when peripheral venous access is not accessible. Various methodologies exist that are used for teaching and learning about cannulation of the IO route both in education and in research. The purpose of the present study was to compare self-efficacy in the cannulation technique for IO access through different techniques.

METHODS

A randomized comparative study was conducted. A total of 118 nursing students participated. The participants were randomly distributed into 2 intervention groups: chicken bone and egg. A checklist was used for data collection to evaluate the IO cannulation technique in nursing students and another to analyze self-efficacy.

RESULTS

The average total score of self-efficacy for all participants was 8.84 (standard deviation (SD) = 0.98). No statistically significant differences were found when comparing the total self-efficacy score and the intervention group ( U = 1604.500; z = -0.733; P = 0.463). No statistically significant differences were found between both groups for the average total score of the procedure ( U = 6916.500; z = -0.939; P = 0.348). The egg group carried out the IO cannulation procedure in a significantly less amount of time (M = 126.88, SD = 82.18) than the chicken bone group (M = 183.77, SD = 108.28), finding statistically significant differences ( U = 4983.500; z = -5.326; P < 0.001).

CONCLUSIONS

Using an egg to teach and learn about IO access could be considered a methodology that is equally effective as using a chicken bone, with the advantage of achieving IO access in a lesser amount of time.

Association of intraosseous and intravenous access with patient outcome in out-of-hospital cardiac arrest

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.

Trends in use of intraosseous and intravenous access in out-of-hospital cardiac arrest across English ambulance services: A registry-based, cohort study

INTRODUCTION

The optimum route for drug administration in cardiac arrest is unclear. Recent data suggest that use of the intraosseous route may be increasing. This study aimed to explore changes over time in use of the intraosseous and intravenous drug routes in out-of-hospital cardiac arrest in England.

METHODS

We extracted data from the UK Out-of-Hospital Cardiac Arrest Outcomes registry. We included adult out-of-hospital cardiac arrest patients between 2015-2020 who were treated by an English Emergency Medical Service that submitted vascular access route data to the registry. The primary outcome was any use of the intraosseous route during cardiac arrest. We used logistic regression models to describe the association between time (calendar month) and intraosseous use.

RESULTS

We identified 75,343 adults in cardiac arrest treated by seven Emergency Medical Service systems between January 2015 and December 2020. The median age was 72 years, 64% were male and 23% presented in a shockable rhythm. Over the study period, the percentage of patients receiving intraosseous access increased from 22.8% in 2015 to 42.5% in 2020. For each study-month, the odds of receiving any intraosseous access increased by 1.019 (95% confidence interval 1.019 to 1.020, p < 0.001). This observed effect was consistent across sensitivity analyses. We observed a corresponding decrease in use of intravenous access.

CONCLUSION

In England, the use of intraosseous access in out-of-hospital cardiac arrest has progressively increased over time. There is an urgent need for randomised controlled trials to evaluate the clinical effectiveness of the different vascular access routes in cardiac arrest.

Intravenous vs. intraosseous vascular access during out-of-hospital cardiac arrest - protocol for a randomised clinical trial

Objective

During cardiac arrest, current guidelines recommend attempting intravenous access first and to consider intraosseous access if intravenous access is unsuccessful or impossible. However, these recommendations are only based on very low-certainty evidence. Therefore, the "Intravenous vs Intraosseous Vascular Access During Out-of-Hospital Cardiac Arrest" (IVIO) trial aims to determine whether there is a difference in patient outcomes depending on the type of vascular access attempted during out-of-hospital cardiac arrest. This current article describes the clinical IVIO trial.

Methods

The IVIO trial is an investigator-initiated, randomised trial of intravenous vs. intraosseous vascular access during adult non-traumatic out-of-hospital cardiac arrest in Denmark. The intervention will consist of minimum two attempts (if unsuccessful on the first attempt) to successfully establish intravenous or intraosseous vascular access during cardiac arrest. The intraosseous group will be further randomised to the humeral or tibial site. The primary outcome is sustained return of spontaneous circulation and key secondary outcomes include survival and survival with a favourable neurological outcome at 30 days. A total of 1,470 patients will be included.

Results

The trial started in March 2022 and the last patient is anticipated to be included in the spring of 2024. The primary results will be reported after 90-day follow-up and are anticipated in mid-2024.

Conclusion

The current article describes the design of the Danish IVIO trial. The findings of this trial will help inform future guidelines for selecting the optimal vascular access route during out-of-hospital cardiac arrest.

Is epinephrine still the drug of choice during cardiac arrest in the emergency department of the hospital? A meta-analysis

Epinephrine is the first-line emergency drug for cardiac arrest and anaphylactic reactions but is reported to be associated with many challenges resulting in its under- or improper utilization. Therefore, in this meta-analysis, the efficacy and safety of epinephrine as a first-line cardiac emergency drug for both out-of-hospital and in-hospital patients was assessed. Pertinent articles were searched in central databases like PubMed, Scopus, and Web of Science, using appropriate keywords as per the PRISMA guidelines. Retrospective and prospective studies were included according to the predefined PICOS criteria. RevMan and MedCalc software were used and statistical parameters such as odds ratio and risk ratio were calculated. Twelve clinical trials with a total of 208,690 cardiac arrest patients from 2000 to 2022 were included, in accordance with the chosen inclusion criteria. In the present meta-analysis, a high odds ratio (OR) value of 3.67 (95 % CI 2.32-5.81) with a tau2 value of 0.64, a chi2 value of 12,446.86, df value of 11, I2 value of 100 %, Z-value 5.53, and a p-value < 0.00001 were reported. Similarly, the risk ratio of 1.89 (95 % CI 1.47-2.43) with a tau2 value of 0.19, chi2 value of 11,530.67, df value of 11, I2 value of 100 %, Z-value of 4.95, and p-value < 0.000001. The present meta-analysis strongly prefers epinephrine injection as the first cardiac emergency drug for both out-of-hospital and in-hospital patients during cardiac arrest.

Focused Ultrasonography in Cardiac Arrest

Rapid diagnostic tools available to the emergency physician caring for cardiac arrest patients are limited. Focused ultrasound (US), and in particular, focused echocardiography, is a useful tool in the evaluation of patients in cardiac arrest. It can help identify possible causes of cardiac arrest like tamponade and pulmonary embolism, which can guide therapy. US can also yield prognostic information, with lack of cardiac activity being highly specific for failure to achieve return of spontaneous circulation. US may also be used to aid in procedural guidance. Recently, focused transesophageal echocardiography has been used in the emergency department setting.

Out-of-Hospital Cardiac Arrest

Survival from out-of-hospital cardiac arrest (OHCA) is predicated on a community and system-wide approach that includes rapid recognition of cardiac arrest, capable bystander CPR, effective basic and advanced life support (BLS and ALS) by EMS providers, and coordinated postresuscitation care. Management of these critically ill patients continues to evolve. This article focuses on the management of OHCA by EMS providers.

Nurses' knowledge and self-assessment of their clinical experiences of intraosseous access: A multicentre cross-sectional study

BACKGROUND

Intraosseous access is an effective and safe option when difficult vascular access occurs. The knowledge, competence, and clinical experience of nurses are collectively essential for the successful implementation of this approach in clinical practice. Education and clinical learning are the main pillars supporting this new practice to ensure patient safety. The aim of this study was to identify the nurses' knowledge and clinical experience of intraosseous access and the factors associated with the adoption of this procedure.

METHODS

A cross-sectional study was carried out from October to December 2020. A convenience sample of 432 nurses from four Italian hospitals were involved. A structured questionnaire was used to assess the nurses' knowledge of the intraosseous access guidelines and their clinical experience.

RESULTS

Most participants were female (71.5%) with more than 10 years of experience (63.7%) working in an emergency (38.9%) and medical (37.7%) setting. Most of the participants demonstrated their knowledge of the use of a device e.g., it is used if vascular access is not rapidly achieved in a child (83.1%) and the boluses of liquids required in the intraosseous procedure (72.7%). A few participants reported having placed intraosseous access (3.5%). A higher level of educational preparation and working in emergency and paediatric settings were associated with increased knowledge.

CONCLUSIONS

Our findings highlighted a sub-optimal level of knowledge of the IO procedure, little experience of this practice in clinical contexts, also associated with a lack of adequate protocols and devices available to nurses. Nurses need to develop their knowledge and practice the skill clinically to embed this practice. University and nurse educators should emphasise the relevance of this practice in nursing education and training, so as to improve the nursing care practice and level of patient safety.

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)

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.

Efficacy of intraosseous access for trauma resuscitation: a systematic review and meta-analysis

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.

Epinephrine administration in adults with out-of-hospital cardiac arrest: A comparison between intraosseous and intravenous route

INTRODUCTION

The benefits and risks of the intraosseous (IO) route for vascular access in patients with out-of-hospital cardiac arrest (OHCA) remain controversial. This study compares the success rates of establishing the access route, epinephrine administration rates, and time-to-epinephrine between adult patients with OHCA with IO access and those with intravenous (IV) access established by paramedics in the prehospital setting.

METHODS

This was a retrospective study conducted by the San-Min station of Taoyuan Fire Department. Data for IV access were collected between January 1, 2020, and December 31, 2020. Data for IO access were collected between January 1, 2021, and March 10, 2021. Inclusion criteria were adult patients with OHCA who received on-scene resuscitation attempts and in whom either IV or IO route access was established by paramedics. Exclusion criteria were missing data, return of spontaneous circulation before establishing vascular access, cardiac arrest en route to hospital, patients not resuscitated, and OHCA unidentified by the dispatcher. Exposure was defined as IV route vs. IO route (EZ-IO®). The outcome measurements were per-patient based success rates of route establishment (successes/attempts), administration rates of epinephrine (epinephrine administered per case/enrolled OHCAs), and odds ratios of IV versus IO on epinephrine administration. We used nonparametric Mann-Whitney rank sum tests for the analysis in continuous variables and Fisher's exact tests for the analysis of categorical variables and the outcomes. Firth logistic regression method was used for sparse data. Factors associated with epinephrine administration other than vascular access were also analyzed. Time-to-epinephrine (defined as time from paramedic arrival to epinephrine injection) was reviewed and calculated by two independent observers and the Kaplan-Meier method was used to compare the two access routes.

RESULTS

A total of 112 adult patients were enrolled in the analysis, including 71 men and 41 women, with an average age of 67 years. There were 90 IV access cases and 22 IO access cases. The groups were compared for median success rates of route establishment (33% vs. 100%, P < 0.001) and administration rates of epinephrine (52% vs. 100%, P < 0.001). The adjusted odds ratio of IO versus IV was 32.445, 95% confidence interval (CI) of 1.844-570.861. Time-to-epinephrine was significantly shorter in the cumulative time-event analysis by the Kaplan-Meier method (P < 0.001).

CONCLUSION

The IO route was significantly associated with higher success rates of route establishment, epinephrine administration, and shorter time-to-epinephrine in the prehospital resuscitation of adult patients with OHCA.

Drug routes in out-of-hospital cardiac arrest: A summary of current evidence

Recent evidence showing the clinical effectiveness of drug therapy in cardiac arrest has led to renewed interest in the optimal route for drug administration in adult out-of-hospital cardiac arrest. Current resuscitation guidelines support use of the intravenous route for intra-arrest drug delivery, with the intraosseous route reserved for patients in whom intravenous access cannot be established. We sought to evaluate current evidence on drug route for administration of cardiac arrest drugs, with a specific focus on the intravenous and intraosseous route. We identified relevant animal, manikin, and human studies through targeted searches of MEDLINE in June 2022. Across pre-hospital systems, there is wide variation in use of the intraosseous route. Early administration of cardiac arrest drugs is associated with improved patient outcomes. Challenges in obtaining intravenous access mean that the intraosseous access may facilitate earlier drug administration. However, time from administration to the central circulation is unclear with pharmacokinetic data limited mainly to animal studies. Observational studies comparing the effect of intravenous and intraosseous drug administration on patient outcomes are challenging to interpret because of resuscitation time bias and other confounders. To date, no randomised controlled trial has directly compared the effect on patient outcomes of intraosseous compared with intravenous drug administration in cardiac arrest. The International Liaison Committee on Resuscitation has described the urgent need for randomised controlled trials comparing the intravenous and intraosseous route in adult out-of-hospital cardiac arrest. Ongoing clinical trials will directly address this knowledge gap.

Septic Shock and Cardiac Arrest in Obstetrics: A Practical Simplified Clinical View

Septic shock and cardiac arrest during pregnancy, despite being uncommon, carry a high mortality rate among pregnant individuals. Basic initial management strategies are fundamental to improve clinical outcomes; obstetricians and maternal-fetal medicine specialists need to be familiar with such interventions.

A narrative review of historic and current approaches for patients with difficult venous access: considerations for the emergency department

INTRODUCTION

Timely placement of vascular access devices is critical during emergent clinical situations; however, challenges in peripheral access can be a common occurrence. Historically, emergency teams have used various approaches to gain peripheral vascular access in situations where traditional means were not feasible; these options have included peripheral venous cutdown, ultrasound-guided peripheral intravenous catheters (PIVs), longer PIVs, central catheters, and intraosseous devices. Each of these options have associated strengths and limitations depending on the clinical situation.

AREAS COVERED

This narrative review reports on the burden of difficult venous access situations and discusses the evidence, and strengths and limitations of vascular access options to help address this challenge. Although first puncture success rates can be high when using alternative methods, significant challenges can include increased procedure time and greater risk of complications. The Easy-Internal Jugular (Easy-IJ) technique is a newer alternative option for patients with difficult venous access that is demonstrated to be safe and effective in emergency care.

EXPERT OPINION

Moving forward, additional clinical studies are required to fully characterize the outcomes associated with the Easy-IJ technique and guidewire-assisted intravenous catheters, as well as to inform guideline development for more comprehensive recommendations on managing challenging or difficult peripheral access situations.

Resuscitation guideline highlights

PURPOSE OF REVIEW

The purpose of this review was to give an overview of the most significant updates in resuscitation guidelines and provide some insights into the new topics being considered in upcoming reviews.

RECENT FINDINGS

Recent updates to resuscitation guidelines have highlighted the importance of the earlier links in the chain-of-survival aimed to improve early recognition, early cardiopulmonary resuscitation (CPR) and defibrillation. Empowering lay rescuers with the support of emergency medical dispatchers or telecommunicators and engaging the community through dispatching volunteers and Automated External Defibrillators, are considered key in improving cardiac arrest outcomes. Novel CPR strategies such as passive insufflation and head-up CPR are being explored, but lack high-certainty evidence. Increased focus on survivorship also highlights the need for more evidence based guidance on how to facilitate the necessary follow-up and rehabilitation after cardiac arrest. Many of the systematic and scoping reviews performed within cardiac arrest resuscitation domains identifies significant knowledge gaps on key elements of our resuscitation practices. There is an urgent need to address these gaps to further improve survival from cardiac arrest in all settings.

SUMMARY

A continuous evidence evaluation process for resuscitation after cardiac arrest is triggered by new evidence or request by the resuscitation community, and provides more current and relevant guidance for clinicians.

Towards individualised treatment of out-of-hospital cardiac arrest patients: an update on technical innovations in the prehospital chain of survival

Out-of-hospital cardiac arrest (OHCA) is a major healthcare problem, with approximately 200 weekly cases in the Netherlands. Its critical, time-dependent nature makes it a unique medical situation, of which outcomes strongly rely on infrastructural factors and on-scene care by emergency medical services (EMS). Survival to hospital discharge is poor, although it has substantially improved, to roughly 25% over the last years. Recognised key factors, such as bystander resuscitation and automated external defibrillator use at the scene, have been markedly optimised with the introduction of technological innovations. In an era with ubiquitous smartphone use, the Dutch digital text message alert platform HartslagNu (www.hartslagnu.nl) increasingly contributes to timely care for OHCA victims. Guidelines emphasise the role of cardiac arrest recognition and early high-quality bystander resuscitation, which calls for education and improved registration at HartslagNu. As for EMS care, new technological developments with future potential are the selective use of mechanical chest compression devices and extracorporeal life support. As a future innovation, ‘smart’ defibrillators are under investigation, guiding resuscitative interventions based on ventricular fibrillation waveform characteristics. Taken together, optimisation of available prehospital technologies is crucial to further improve OHCA outcomes, with particular focus on more available trained volunteers in the first phase and additional research on advanced EMS care in the second phase.

Singapore Advanced Cardiac Life Support Guidelines 2021

Advanced cardiac life support (ACLS) emphasises the use of advanced airway management and ventilation, circulatory support and the appropriate use of drugs in resuscitation, as well as the identification of reversible causes of cardiac arrest. Extracorporeal cardiopulmonary resuscitation and organ donation, as well as special circumstances including drowning, pulmonary embolism and pregnancy are addressed. Resuscitation does not end with ACLS but must continue in post-resuscitation care. ACLS also covers the recognition and management of unstable pre-arrest tachy- and bradydysrhythmias that may deteriorate further.

Impact of intraosseous versus intravenous resuscitation during in-hospital cardiac arrest: A retrospective study

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.

Outcomes of In-hospital Cardiac Arrest: A Review of the Evidence

Cardiac arrest is a significant cause of morbidity and mortality in the United States. Cardiac arrest can occur in the community or among hospitalized patients. There are many commonalities between in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest; however, significant differences exist. Optimizing outcomes for patients with IHCA depends on high-quality care supported by the best available evidence. It is essential that critical care nurses are familiar with the evidence related to IHCA. This article focuses on a review of the evidence on IHCA, focusing on practical implications for critical care nursing practice.

Staying InformED: Top emergency Medicine pharmacotherapy articles of 2020

The year 2020 was not easy for Emergency Medicine (EM) clinicians with the burden of tackling a pandemic. A large focus, rightfully so, was placed on the evolving diagnosis and management of patients with COVID-19 and, as such, the ability of clinicians to remain up to date on key EM pharmacotherapy literature may have been compromised. This article reviews the most important EM pharmacotherapy publications indexed in 2020. A modified Delphi approach was utilized for selected journals to identify the most impactful EM pharmacotherapy studies. A total of fifteen articles, eleven trials and four meta-analyses, were identified. This review provides a summary of each study, along with a commentary on the impact to the EM literature and EM clinician.

[Adult advanced life support]

These European Resuscitation Council Advanced Life Support guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.

Comparison of intravascular access methods applied by nurses wearing personal protective equipment in simulated COVID-19 resuscitation: A randomized crossover simulation trial

BACKGROUND

Prehospital emergency care of children is challenging. In the era of the COVID-19 pandemic, when medical personnel should use personal protective equipment against aerosol-generating procedures, the efficiency of medical procedures may decrease. The study objective was to evaluate the effectiveness of different intravascular access methods applied by nurses wearing biosafety Level-2 suits in simulated paediatric COVID-19 resuscitation.

METHODS

A prospective, randomized, crossover, single-blinded simulation trial was performed. Nursing staff attending Advanced Cardiovascular Life Support courses accredited by the American Heart Association participated in the study. A total of 65 nurses were recruited and randomly assigned to different study groups. They received standard training on intravascular access methods employing distinct devices. The participants wore biosafety Level-2 suits and performed vascular access with the following intraosseous devices: NIO-P, EZ-IO, and Jamshidi needle; intravenous (IV) access was used as a reference method. Both the order of participants and the access methods were random. Each participant performed intravascular access with each of the four methods tested. The effectiveness of the first attempt to obtain intravascular access and the following time parameters were analysed: the time between grasping the intravascular device out of the original packing until infusion line connection. The ease of the procedure was measured with a visual analogue scale (1 - easy; 10 - difficult).

RESULTS

The first attempt success rate of intravascular access by using NIO-P and EZ-IO equalled 100% and was statistically significantly higher than that with the Jamshidi needle (80.0%; p = 0.02) and with the IV method (69.2%; p = 0.005). The time required to connect the infusion line varied and amounted to 33 ± 4 s for NIO-P compared to 37 ± 6.7 s for EZ-IO (p<0.001), 43 ± 7 s for Jamshidi (p<0.001), and 98.5 ± 10 s for IV access (p<0.001). The procedure was easiest in the case of NIO-P and EZ-IO (2 ± 1 points; p=1.0) compared with Jamshidi (5 ± 3 points; p<0.001) and IV access (7 ± 2 points; p<0.001).

CONCLUSION

The study provides evidence that nurses wearing biosafety Level-2 suits were able to obtain intraosseous access faster and more effectively as compared with IV access during simulated COVID-19 paediatric resuscitation. The most effective method of intravascular access was the NIO-P intraosseous device. Further clinical trials are necessary to confirm the results.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

Adrenaline to improve survival in out-of-hospital cardiac arrest: the PARAMEDIC2 RCT

BACKGROUND

Adrenaline has been used as a treatment for cardiac arrest for many years, despite uncertainty about its effects on long-term outcomes and concerns that it may cause worse neurological outcomes.

OBJECTIVES

The objectives were to evaluate the effects of adrenaline on survival and neurological outcomes, and to assess the cost-effectiveness of adrenaline use.

DESIGN

This was a pragmatic, randomised, allocation-concealed, placebo-controlled, parallel-group superiority trial and economic evaluation. Costs are expressed in Great British pounds and reported in 2016/17 prices.

SETTING

This trial was set in five NHS ambulance services in England and Wales.

PARTICIPANTS

Adults treated for an out-of-hospital cardiac arrest were included. Patients were ineligible if they were pregnant, if they were aged < 16 years, if the cardiac arrest had been caused by anaphylaxis or life-threatening asthma, or if adrenaline had already been given.

INTERVENTIONS

Participants were randomised to either adrenaline (1 mg) or placebo in a 1 : 1 allocation ratio by the opening of allocation-concealed treatment packs.

MAIN OUTCOME MEASURES

The primary outcome was survival to 30 days. The secondary outcomes were survival to hospital admission, survival to hospital discharge, survival at 3, 6 and 12 months, neurological outcomes and health-related quality of life through to 6 months. The economic evaluation assessed the incremental cost per quality-adjusted life-year gained from the perspective of the NHS and Personal Social Services. Participants, clinical teams and those assessing patient outcomes were masked to the treatment allocation.

RESULTS

From December 2014 to October 2017, 8014 participants were assigned to the adrenaline (n = 4015) or to the placebo (n = 3999) arm. At 30 days, 130 out of 4012 participants (3.2%) in the adrenaline arm and 94 out of 3995 (2.4%) in the placebo arm were alive (adjusted odds ratio for survival 1.47, 95% confidence interval 1.09 to 1.97). For secondary outcomes, survival to hospital admission was higher for those receiving adrenaline than for those receiving placebo (23.6% vs. 8.0%; adjusted odds ratio 3.83, 95% confidence interval 3.30 to 4.43). The rate of favourable neurological outcome at hospital discharge was not significantly different between the arms (2.2% vs. 1.9%; adjusted odds ratio 1.19, 95% confidence interval 0.85 to 1.68). The pattern of improved survival but no significant improvement in neurological outcomes continued through to 6 months. By 12 months, survival in the adrenaline arm was 2.7%, compared with 2.0% in the placebo arm (adjusted odds ratio 1.38, 95% confidence interval 1.00 to 1.92). An adjusted subgroup analysis did not identify significant interactions. The incremental cost-effectiveness ratio for adrenaline was estimated at £1,693,003 per quality-adjusted life-year gained over the first 6 months after the cardiac arrest event and £81,070 per quality-adjusted life-year gained over the lifetime of survivors. Additional economic analyses estimated incremental cost-effectiveness ratios for adrenaline at £982,880 per percentage point increase in overall survival and £377,232 per percentage point increase in neurological outcomes over the first 6 months after the cardiac arrest.

LIMITATIONS

The estimate for survival with a favourable neurological outcome is imprecise because of the small numbers of patients surviving with a good outcome.

CONCLUSIONS

Adrenaline improved long-term survival, but there was no evidence that it significantly improved neurological outcomes. The incremental cost-effectiveness ratio per quality-adjusted life-year exceeds the threshold of £20,000-30,000 per quality-adjusted life-year usually supported by the NHS.

FUTURE WORK

Further research is required to better understand patients' preferences in relation to survival and neurological outcomes after out-of-hospital cardiac arrest and to aid interpretation of the trial findings from a patient and public perspective.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN73485024 and EudraCT 2014-000792-11.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 25. See the NIHR Journals Library website for further project information.

European Resuscitation Council Guidelines 2021: Adult advanced life support

These European Resuscitation Council Advanced Life Support guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the prevention of and ALS treatments for both in-hospital cardiac arrest and out-of-hospital cardiac arrest.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

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

Background

Intraosseous (IO) drug delivery may be necessary in emergency situations when intravenous access is unattainable. Valproic acid (VPA) is a histone deacetylase inhibitor that has previously been shown to improve survival in preclinical models of lethal polytrauma. In this study, we sought to compare serum levels of intravenously and IO-delivered VPA, and to analyze the effect of IO-delivered VPA.

Methods

Swine were subjected to 40% blood volume hemorrhage, brain injury, femur fracture, rectus crush injury and liver laceration. After 1 hour of shock, animals were randomized (n=3/group) to receive normal saline resuscitation (control), normal saline+intravenous VPA 150 mg/kg (intravenous group) or normal saline +IO VPA 150 mg/kg (IO group). Serum levels of VPA were assessed between groups, and proteomics analyses were performed on IO and control groups on heart, lung and liver samples.

Results

Intravenous and IO serum VPA levels were similar at 1, 3, 5 and 7 hours after starting the infusion (p>0.05). IO-delivered VPA induced significant proteomics changes in the heart, lung and liver, which were most pronounced in the lung. Biologic processes affected included inflammation, metabolism and transcriptional & translational machinery. The control group had 0% survival, and the intravenous and IO group both had 100% survival to the end of the experiment (p<0.05).

Discussion

IO-delivered VPA is noninferior to intravenous administration and is a viable option in emergent situations when intravenous access is unattainable.

Level of evidence

Not applicable (animal study).

Intraosseous versus intravenous vascular access during cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a systematic review and meta-analysis of observational studies

INTRODUCTION

This study is aimed to investigate the association of intraosseous (IO) versus intravenous (IV) route during cardiopulmonary resuscitation (CPR) with outcomes after out-of-hospital cardiac arrest (OHCA).

METHODS

We systematically searched PubMed, Embase, Cochrane Library and Web of Science from the database inception through April 2020. Our search strings included designed keywords for two concepts, i.e. vascular access and cardiac arrest. There were no limitations implemented in the search strategy. We selected studies comparing IO versus IV access in neurological or survival outcomes after OHCA. Favourable neurological outcome at hospital discharge was pre-specified as the primary outcome. We pooled the effect estimates in random-effects models and quantified the heterogeneity by the I² statistics. Time to intervention, defined as time interval from call for emergency medical services to establishing vascular access or administering medications, was hypothesized to be a potential outcome moderator and examined in subgroup analysis with meta-regression.

RESULTS

Nine retrospective observational studies involving 111,746 adult OHCA patients were included. Most studies were rated as high quality according to Newcastle-Ottawa Scale. The pooled results demonstrated no significant association between types of vascular access and the primary outcome (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.27-1.33; I², 95%). In subgroup analysis, time to intervention was noted to be positively associated with the pooled OR of achieving the primary outcome (OR: 3.95, 95% CI, 1.42-11.02, p: 0.02). That is, when the studies not accounting for the variable of "time to intervention" in the statistical analysis were pooled together, the meta-analytic results between IO access and favourable outcomes would be biased toward inverse association. No obvious publication bias was detected by the funnel plot.

CONCLUSIONS

The meta-analysis revealed no significant association between types of vascular access and neurological outcomes at hospital discharge among OHCA patients. Time to intervention was identified to be an important outcome moderator in this meta-analysis of observation studies. These results call for the need for future clinical trials to investigate the unbiased effect of IO use on OHCA CPR.

Intraosseous or Peripheral IV Access in Pediatric Cardiac Arrest? Results From the French National Cardiac Arrest Registry

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.

Resuscitation highlights in 2020

BACKGROUND

This review is the latest in a series of regular annual reviews undertaken by the editors and aims to highlight some of the key papers published in Resuscitation during 2020. The number of papers submitted to the Journal in 2020 increased by 25% on the previous year.MethodsHand-searching by the editors of all papers published in Resuscitation during 2020. Papers were selected based on then general interest and novelty and were categorised into general themes.ResultsA total of 103 papers were selected for brief mention in this review.ConclusionsResuscitation science continues to evolve rapidly and incorporate all links in the chain of survival.

2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid.Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed.All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published.Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.

Translation from animal studies of novel pharmacological therapies to clinical trials in cardiac arrest: A systematic review

BACKGROUND

There is a lack of new promising therapies to improve the dismal outcomes from cardiac arrest. The objectives of this study were: (1) To identify novel pharmacological therapies investigated in experimental animal studies and (2) to identify pharmacological therapies translated from experimental animal studies to clinical trials.

METHODS

PubMed was searched to first identify relevant experimental cardiac arrest animal models published within the last 20 years. Based on this, a list of interventions was created and a second search was performed to identify clinical trials testing one of these interventions. Data extraction was performed using standardised data extraction forms.

RESULTS

We identified 415 animal studies testing 190 different pharmacological interventions. The most commonly tested interventions were classified as vasopressors, anaesthetics/gases, or interventions aimed at molecular targets. We found 43 clinical trials testing 26 different interventions identified in the animal studies. Of these, 13 trials reported positive findings and 30 trials reported neutral findings with regards to the primary endpoint. No study showed harm of the intervention. Some interventions tested in human clinical trials, had previously been tested in animal studies without a positive effect on outcomes. A large number of animal studies was performed after publication of a clinical trial.

CONCLUSION

Numerous different pharmacological interventions have been tested in experimental animal models. Despite this only a limited number of these interventions have advanced to clinical trials, however several of the clinical trials tested interventions that were first tested in experimental animal models.