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Brebner C, Asamoah-Boaheng M, Zaidel B, Yap J, Scheuermeyer F, Mok V, Hutton J, Meckler G, Schlamp R, Christenson J, Grunau B. The association of intravenous vs. humeral-intraosseous vascular access with patient outcomes in adult out-of-hospital cardiac arrests. Resuscitation 2024; 202:110360. [PMID: 39154890 DOI: 10.1016/j.resuscitation.2024.110360] [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: 06/06/2024] [Revised: 07/16/2024] [Accepted: 08/11/2024] [Indexed: 08/20/2024]
Abstract
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.
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Affiliation(s)
- Callahan Brebner
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Michael Asamoah-Boaheng
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C., Canada
| | - Bianca Zaidel
- Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Justin Yap
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada
| | - Frank Scheuermeyer
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C., Canada
| | - Valerie Mok
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Jacob Hutton
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; British Columbia Emergency Health Services, British Columbia, Canada
| | - Garth Meckler
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada
| | - Robert Schlamp
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; British Columbia Emergency Health Services, British Columbia, Canada
| | - Jim Christenson
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C., Canada
| | - Brian Grunau
- British Columbia Resuscitation Research Collaborative, British Columbia, Canada; Faculty of Medicine, University of British Columbia, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, B.C., Canada; British Columbia Emergency Health Services, British Columbia, Canada.
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Meilandt C, Fink Vallentin M, Blumensaadt Winther K, Bach A, Dissing TH, Christensen S, Juhl Terkelsen C, Lass Klitgaard T, Mikkelsen S, Folke F, Granfeldt A, Andersen LW. Intravenous vs. intraosseous vascular access during out-of-hospital cardiac arrest - protocol for a randomised clinical trial. Resusc Plus 2023; 15:100428. [PMID: 37502742 PMCID: PMC10368931 DOI: 10.1016/j.resplu.2023.100428] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/27/2023] [Indexed: 07/29/2023] Open
Abstract
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.
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Affiliation(s)
- Carsten Meilandt
- Prehospital Emergency Medical Services, Central Denmark Region, Denmark
| | | | | | - Allan Bach
- Prehospital Emergency Medical Services, Central Denmark Region, Denmark
| | - Thomas H. Dissing
- Prehospital Emergency Medical Services, Central Denmark Region, Denmark
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | - Steffen Christensen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Aarhus University, Denmark
| | | | | | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Denmark
| | - Fredrik Folke
- Copenhagen Emergency Medical Services, Capital Region of Denmark, Denmark
- Department of Cardiology, Herlev Gentofte University Hospital, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Asger Granfeldt
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Aarhus University, Denmark
| | - Lars W. Andersen
- Prehospital Emergency Medical Services, Central Denmark Region, Denmark
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Aarhus University, Denmark
- Department of Anesthesiology and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
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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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Hooper A, Nolan JP, Rees N, Walker A, Perkins GD, Couper K. Drug routes in out-of-hospital cardiac arrest: A summary of current evidence. Resuscitation 2022; 181:70-78. [PMID: 36309248 DOI: 10.1016/j.resuscitation.2022.10.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Amy Hooper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jerry P Nolan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - Nigel Rees
- Pre-hospital Emergency Response Unit, Welsh Ambulance Services NHS Trust, St Asaph, UK; Institute of Life Sciences, Swansea University, Swansea, UK
| | - Alison Walker
- West Midlands Ambulance Service University NHS Foundation Trust, Brierley Hill, UK; Department of Emergency Medicine, Harrogate and District NHS Foundation Trust, Harrogate, UK
| | - Gavin D Perkins
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Keith Couper
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.
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Lescroart M, Pressiat C, Péquignot B, Tran N, Hébert JL, Alsagheer N, Gambier N, Ghaleh B, Scala-Bertola J, Levy B. Impaired Pharmacokinetics of Amiodarone under Veno-Venous Extracorporeal Membrane Oxygenation: From Bench to Bedside. Pharmaceutics 2022; 14:974. [PMID: 35631560 PMCID: PMC9147299 DOI: 10.3390/pharmaceutics14050974] [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: 04/04/2022] [Revised: 04/25/2022] [Accepted: 04/27/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Adjusting drug therapy under veno-venous extracorporeal membrane oxygenation (VV ECMO) is challenging. Although impaired pharmacokinetics (PK) under VV ECMO have been reported for sedative drugs and antibiotics, data about amiodarone are lacking. We evaluated the pharmacokinetics of amiodarone under VV ECMO both in vitro and in vivo. METHODS In vitro: Amiodarone concentration decays were compared between closed-loop ECMO and control stirring containers over a 24 h period. In vivo: Potassium-induced cardiac arrest in 10 pigs with ARDS, assigned to either control or VV ECMO groups, was treated with 300 mg amiodarone injection under continuous cardiopulmonary resuscitation. Pharmacokinetic parameters Cmax, Tmax AUC and F were determined from both direct amiodarone plasma concentrations observation and non-linear mixed effects modeling estimation. RESULTS An in vitro study revealed a rapid and significant decrease in amiodarone concentrations in the closed-loop ECMO circuitry whereas it remained stable in control experiment. In vivo study revealed a 32% decrease in the AUC and a significant 42% drop of Cmax in the VV ECMO group as compared to controls. No difference in Tmax was observed. VV ECMO significantly modified both central distribution volume and amiodarone clearance. Monte Carlo simulations predicted that a 600 mg bolus of amiodarone under VV ECMO would achieve the amiodarone bioavailability observed in the control group. CONCLUSIONS This is the first study to report decreased amiodarone bioavailability under VV ECMO. Higher doses of amiodarone should be considered for effective amiodarone exposure under VV ECMO.
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Affiliation(s)
- Mickaël Lescroart
- Service de Médecine Intensive et Réanimation, Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Hôpital Brabois, 54000 Nancy, France; (B.P.); (B.L.)
- Groupe Choc, Équipe 2, INSERM U 1116, Faculté de Médecine, 54000 Nancy, France
- Faculté de Médecine, Université de Lorraine, 54000 Nancy, France;
| | - Claire Pressiat
- Laboratoire de Pharmacologie, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Université Paris Est-Créteil, 94000 Créteil, France;
- Team 3, INSERM U955, Université Paris Est Créteil, Université Paris-Est, 94010 Créteil, France
- UMR S955, DHU A-TVB, Université Paris-Est Créteil (UPEC), Université Paris-Est, 94000 Créteil, France
| | - Benjamin Péquignot
- Service de Médecine Intensive et Réanimation, Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Hôpital Brabois, 54000 Nancy, France; (B.P.); (B.L.)
- Groupe Choc, Équipe 2, INSERM U 1116, Faculté de Médecine, 54000 Nancy, France
- Faculté de Médecine, Université de Lorraine, 54000 Nancy, France;
| | - N’Guyen Tran
- Faculté de Médecine, Université de Lorraine, 54000 Nancy, France;
- École de Chirurgie, Faculté de Médecine, Université de Lorraine, 54000 Nancy, France
| | - Jean-Louis Hébert
- Institut de Cardiologie, Hôpital Pitié-Salpêtrière, CHU Pitié-Salpêtrière, AP-HP, Université de la Sorbonne, Boulevard de L’Hôpital, 75013 Paris, France;
| | - Nassib Alsagheer
- Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Service de Pharmacologie Clinique et Toxicologie, Université de Lorraine, 54000 Nancy, France; (N.A.); (N.G.); (J.S.-B.)
| | - Nicolas Gambier
- Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Service de Pharmacologie Clinique et Toxicologie, Université de Lorraine, 54000 Nancy, France; (N.A.); (N.G.); (J.S.-B.)
- CNRS, IMoPA, Université de Lorraine, 54000 Nancy, France
| | - Bijan Ghaleh
- U955-IMRB, Inserm, Université Paris-Est Créteil (UPEC), École Nationale Vétérinaire d’Alfort, Maisons-Alfort, 94000 Créteil, France;
| | - Julien Scala-Bertola
- Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Service de Pharmacologie Clinique et Toxicologie, Université de Lorraine, 54000 Nancy, France; (N.A.); (N.G.); (J.S.-B.)
- CNRS, IMoPA, Université de Lorraine, 54000 Nancy, France
| | - Bruno Levy
- Service de Médecine Intensive et Réanimation, Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Hôpital Brabois, 54000 Nancy, France; (B.P.); (B.L.)
- Groupe Choc, Équipe 2, INSERM U 1116, Faculté de Médecine, 54000 Nancy, France
- Faculté de Médecine, Université de Lorraine, 54000 Nancy, France;
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Andersen LW, Holmberg MJ, Granfeldt A, Vallentin MF. Calcium administration and post-cardiac arrest ionized calcium values according to intraosseous or intravenous administration - A post hoc analysis of a randomized trial. Resuscitation 2021; 170:211-212. [PMID: 34929298 DOI: 10.1016/j.resuscitation.2021.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 12/10/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Lars W Andersen
- Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark; Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark; Research Center for Emergency Medicine, Department of Clinical Medicine and Emergency Department, Aarhus University and Aarhus University Hospital, Aarhus, Denmark.
| | - Mathias J Holmberg
- Research Center for Emergency Medicine, Department of Clinical Medicine and Emergency Department, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Anesthesiology and Intensive Care, Randers Regional Hospital, Denmark
| | - Asger Granfeldt
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
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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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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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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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Christ M, von Auenmüller KI, von den Benken T, Fessaras S, Dierschke W, Trappe HJ. [Supraglottic airway devices and intraosseous access in the treatment of patients after out-of-hospital cardiac arrest : Do we use the wrong tool too often?]. Med Klin Intensivmed Notfmed 2018; 114:426-433. [PMID: 30353227 DOI: 10.1007/s00063-018-0502-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/21/2018] [Accepted: 10/03/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Only a little is known about the frequency of use of supraglottic airway devices (SADs) and intraosseous (IO) access in patients who have had out-of-hospital cardiac arrest (OHCA). MATERIALS AND METHODS We analyzed data from all patients who had had OHCA admitted to our hospital between 1 January 2008 and 31 December 2017. RESULTS A total of 135 (33.8%) patients who had had OHCA were admitted with a SAD, 223 (55.8%) with an endotracheal tube, 3 (0.8%) with mask ventilation, and 32 (8.0%) breathed spontaneously on admission to hospital. Three hundred and twenty-eight patients (82.0%) were admitted with a peripheral intravenous line, one (0.3%) with a central venous catheter, one (0.3%) with a port catheter, and 32 (8.0%) with IO access. CONCLUSIONS Irrespective of an increasing number of studies that raise the question whether the airway management of patients who have had OHCA using an SGA might be inferior to that with endotracheal tubes, approximately one third of all patients who have had OHCA were admitted with an SAD in this study. On the other hand, IO access is significantly less frequently used, despite fewer critical study results overall.
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Affiliation(s)
- M Christ
- Medizinische Klinik II, Schwerpunkt Kardiologie und Angiologie, Marien Hospital Herne, Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Deutschland.
| | - K I von Auenmüller
- Medizinische Klinik II, Schwerpunkt Kardiologie und Angiologie, Marien Hospital Herne, Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Deutschland
| | - T von den Benken
- Medizinische Klinik II, Schwerpunkt Kardiologie und Angiologie, Marien Hospital Herne, Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Deutschland
| | - S Fessaras
- Medizinische Klinik II, Schwerpunkt Kardiologie und Angiologie, Marien Hospital Herne, Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Deutschland
| | - W Dierschke
- Medizinische Klinik II, Schwerpunkt Kardiologie und Angiologie, Marien Hospital Herne, Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Deutschland
| | - H-J Trappe
- Medizinische Klinik II, Schwerpunkt Kardiologie und Angiologie, Marien Hospital Herne, Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Deutschland
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