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Nilsson FN, Bie-Bogh S, Milling L, Hansen PM, Pedersen H, Christensen EF, Knudsen JS, Christensen HC, Folke F, Høen-Beck D, Væggemose U, Brøchner AC, Mikkelsen S. Association of intraosseous and intravenous access with patient outcome in out-of-hospital cardiac arrest. Sci Rep 2023; 13:20796. [PMID: 38012312 PMCID: PMC10682403 DOI: 10.1038/s41598-023-48350-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 11/25/2023] [Indexed: 11/29/2023] Open
Abstract
Here we report the results of a study on the association between drug delivery via intravenous route or intraosseous route in out-of-hospital cardiac arrest. Intraosseous drug delivery is considered an alternative option in resuscitation if intravenous access is difficult or impossible. Intraosseous uptake of drugs may, however, be compromised. We have performed a retrospective cohort study of all Danish patients with out-of-hospital cardiac arrest in the years 2016-2020 to investigate whether mortality is associated with the route of drug delivery. Outcome was 30-day mortality, death at the scene, no prehospital return of spontaneous circulation, and 7- and 90-days mortality. 17,250 patients had out-of-hospital cardiac arrest. 6243 patients received no treatment and were excluded. 1908 patients had sustained return of spontaneous circulation before access to the vascular bed was obtained. 2061 patients were unidentified, and 286 cases were erroneously registered. Thus, this report consist of results from 6752 patients. Drug delivery by intraosseous route is associated with increased OR of: No spontaneous circulation at any time (OR 1.51), Death at 7 days (OR 1.94), 30 days (2.02), and 90 days (OR 2.29). Intraosseous drug delivery in out-of-hospital cardiac arrest is associated with overall poorer outcomes than intravenous drug delivery.
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Affiliation(s)
- Frederik Nancke Nilsson
- The Prehospital Research Unit, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Søren Bie-Bogh
- OPEN, Open Patient Data Explorative Network, University of Southern Denmark, Odense, Denmark
| | - Louise Milling
- The Prehospital Research Unit, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, North Zealand Hospital, Hillerød, Denmark
| | - Peter Martin Hansen
- The Prehospital Research Unit, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- The Danish Air Ambulance, Aarhus, Denmark
| | - Helena Pedersen
- The Prehospital Research Unit, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Erika F Christensen
- Department of Clinical Medicine, Centre for Prehospital and Emergency Research, Aalborg University Hospital, Aalborg University, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jens Stubager Knudsen
- The Danish Air Ambulance, Aarhus, Denmark
- Department of Anaesthesiology, Kolding University Hospital, Kolding, Denmark
| | - Helle Collatz Christensen
- Prehospital Center, University of Copenhagen, Naestved, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Danish Clinical Quality Program (RKKP), National Clinical Registries, Copenhagen, Denmark
| | - Fredrik Folke
- Copenhagen Emergency Medical Services, University of Copenhagen, Ballerup, Denmark
- Department of Cardiology, Herlev Gentofte University Hospital, Copenhagen, Denmark
| | - David Høen-Beck
- Department of Anaesthesiology, Denmark and Prehospital Center, Holbæk Hospital, HolbækRegion Zealand, Denmark
| | - Ulla Væggemose
- Department of Research and Development, Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne Craveiro Brøchner
- The Prehospital Research Unit, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Anaesthesiology, Kolding University Hospital, Kolding, Denmark
| | - Søren Mikkelsen
- The Prehospital Research Unit, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark.
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, 5000, Odense C, Denmark.
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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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Feinstein BA, Stubbs BA, Rea T, Kudenchuk PJ. Intraosseous compared to intravenous drug resuscitation in out-of-hospital cardiac arrest. Resuscitation 2017. [PMID: 28629995 DOI: 10.1016/j.resuscitation.2017.06.014] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS Although the intraosseous (IO) route is increasingly used for vascular access in out-of-hospital cardiac arrest (OHCA), little is known about its comparative effectiveness relative to intravenous (IV) access. We evaluated clinical outcomes following OHCA comparing drug administration via IO versus IV routes. METHODS This retrospective cohort study evaluated Emergency Medical Services (EMS)-treated adults with atraumatic OHCA in a large metropolitan EMS system between 9/1/2012-12/31/2014. Access was classified as IO or IV based on the route of first EMS drug administration. Study endpoints were survival to hospital discharge, return of spontaneous circulation (ROSC) and survival to hospital admission. RESULTS Among 2164 adults with OHCA, 1800 met eligibility criteria, 1525 of whom were treated via IV and 275 principally via tibial-IO routes. Compared to IV, IO-treated patients were younger, more often women, had unwitnessed OHCA, a non-cardiac aetiology, and presented with non-shockable rhythms. IO versus IV-treated patients were less likely to survive to hospital discharge (14.9% vs 22.8%, p=0.003), achieve ROSC (43.6% vs 55.5%, p<0.001) or be hospitalized (38.5% vs 50.0% p<0.001). In multivariable adjusted analyses, IO treatment was not associated with survival to discharge (odds ratio (OR) (95% confidence interval) 0.81 (0.55, 1.21), p=0.31), but was associated with a lower likelihood of ROSC (OR=0.67 (0.50, 0.88), p=0.004) and survival to hospitalization (OR=0.68 (0.51, 0.91), p=0.009). CONCLUSION Though not independently associated with survival to discharge, principally tibial IO versus IV treatment was associated with a lower likelihood of ROSC and hospitalization. How routes of vascular access influence clinical outcomes after OHCA merits additional study.
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Affiliation(s)
| | - Benjamin A Stubbs
- Department of Family Medicine, University of Washington, United States
| | - Tom Rea
- Department of Medicine, University of Washington, United States
| | - Peter J Kudenchuk
- Department of Medicine, Division of Cardiology, University of Washington, Box 356422, 1959 NE Pacific Street, Seattle, WA, 98195-6422, United States.
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