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

Mikael F Vallentin¹, Asger Granfeldt¹, Thomas L Klitgaard¹

¹From Prehospital Emergency Medical Services, Central Denmark Region (M.F.V., A.L.P., A.H.P., S.W., L.W.F., C.M., K.B.W., A.B., T.H.D., L.K.R., L.R.M., M.L.L., T.E., A.G.N., C.R., L.W.A.), the Department of Clinical Medicine, Aarhus University (M.F.V., A.G., C.J.T., S.C., L.W.A.), and the Departments of Anesthesiology and Intensive Care (A.G., M.J.H., T.H.D., S.C., C.G.N., B.S., L.W.A.), Cardiology (C.J.T.), and Radiology (E.K.), Aarhus University Hospital, Aarhus, the Department of Anesthesiology and Intensive Care, Aalborg University Hospital (T.L.K., F.M.N.), the Center for Prehospital and Emergency Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital (E.F.C.), and Emergency Medical Services, North Denmark Region (P.B.), Aalborg, the Prehospital Research Unit (S.M., P.M.H.) and Emergency Medical Services (J.H.H., M.B., L.-G.R.N., M.P., G.K.-A., P.M.H.), Region of Southern Denmark, the Department of Anesthesiology and Intensive Care, Odense University Hospital (J.H.H., M.B.), and the Department of Regional Health Research, University of Southern Denmark (A.C.B.), Odense, the Departments of Cardiology (F.F.) and of Anesthesiology and Intensive Care (L.R.), Copenhagen University Hospital, Gentofte Copenhagen University Hospital-Emergency Medical Services, Ballerup (F.F., J.W.B., H.A., S.H., T.H.F.), the Department of Clinical Medicine, University of Copenhagen (F.F., H.C.C., L.R., M.K.), and the Department of Cardiology, the Heart Center, Copenhagen University Hospital, Rigshospitalet (L.E.R.O., S.L.D.H.), Copenhagen, the Prehospital Center, Region Zealand, Næstved (H.C.C.), the Department of Anesthesiology and Intensive Care, Gødstrup Regional Hospital, Gødstrup (L.K.R.), the Department of Anesthesiology and Intensive Care, Randers Regional Hospital, Randers (L.R.M., T.E.), the Department of Anesthesiology and Intensive Care, Viborg Regional Hospital, Viborg (A.G.N.), the Elective Surgery Center, Silkeborg Regional Hospital, Silkeborg (C.R.), the Department of Anesthesiology and Intensive Care, University Hospital of Southern Denmark, Esbjerg and Grindsted, Esbjerg (L.-G.R.N.), the Department of Anesthesiology and Intensive Care, University Hospital of Southern Denmark, Kolding (M.P., A.C.B.), the Department of Anesthesiology and Intensive Care, University Hospital of Southern Denmark, Aabenraa (G.K.-A.), the Department of Anesthesiology and Intensive Care, Svendborg Hospital, Svendborg (P.M.H.), the Department of Anesthesiology and Intensive Care, Copenhagen University Hospital, Herlev (H.A.), the Department of Anesthesiology and Intensive Care, Copenhagen University Hospital-North Zealand, Hillerød (S.H.), the Department of Anesthesiology and Intensive Care, Zealand University Hospital, Køge (J.U.H.B.), the Department of Anesthesiology and Intensive Care, Nykøbing Falster Hospital, Nykøbing Falster (K.J.), the Department of Anesthesiology and Intensive Care, Holbæk Hospital, Holbæk (M.K.), and the Department of Anesthesiology and Intensive Care, Slagelse Hospital, Slagelse (M.S.) - all in Denmark.

The New England Journal of Medicine

|October 31, 2024

Summary

In out-of-hospital cardiac arrest, initial intraosseous vascular access showed no significant difference in sustained return of spontaneous circulation compared to intravenous access. Both methods are crucial for drug delivery during resuscitation efforts.

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Area of Science:

Emergency Medicine
Cardiology
Critical Care

Background:

Out-of-hospital cardiac arrest (OHCA) is a major global cause of mortality.
Effective vascular access is essential for drug administration during cardiopulmonary resuscitation (CPR).
Intraosseous (IO) and intravenous (IV) routes are commonly used, but their comparative effectiveness is not well-established.

Purpose of the Study:

To compare the effectiveness of initial intraosseous versus intravenous vascular access in adults with non-traumatic OHCA.
To evaluate sustained return of spontaneous circulation (ROSC) as the primary outcome.
To assess secondary outcomes including 30-day survival and 30-day survival with favorable neurologic outcome.

Main Methods:

A randomized clinical trial was conducted involving adult patients with non-traumatic OHCA.
Participants were randomized to receive initial IO or IV vascular access.
Outcomes measured included successful access within two attempts, sustained ROSC, 30-day survival, and neurologic function using the modified Rankin scale.

Main Results:

Successful vascular access within two attempts was higher in the IO group (92%) compared to the IV group (80%).
Sustained ROSC occurred in 30% of the IO group and 29% of the IV group (Risk Ratio [RR] 1.06; 95% CI, 0.90 to 1.24).
30-day survival rates were 12% for IO and 10% for IV (RR 1.16; 95% CI, 0.87 to 1.56), with similar rates for favorable neurologic outcome.

Conclusions:

No significant difference was found in sustained ROSC between initial IO and IV vascular access in OHCA patients.
While IO access was more frequently successful within two attempts, this did not translate to a significant difference in key clinical outcomes.
The study provides evidence that both IO and IV routes are viable options for vascular access during resuscitation for OHCA.