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Comparison of Drug Routes in Out-of-Hospital Cardiac Arrest
TAKE-HOME MESSAGE
- In this randomized trial involving 6082 adult patients with out-of-hospital cardiac arrest, an intraosseous-first vascular access strategy was safe but did not significantly improve 30-day survival or neurological outcomes at hospital discharge compared with an intravenous-first strategy. However, the intraosseous-first strategy was associated with slightly lower odds of achieving the return of spontaneous circulation at any time.
- These findings suggest that intraosseous-first and intravenous-first vascular access strategies offer comparable efficacy in managing adult patients with out-of-hospital cardiac arrest.
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
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.).
Additional Info
A Randomized Trial of Drug Route in Out-of-Hospital Cardiac Arrest
N. Engl. J. Med 2024 Oct 31;[EPub Ahead of Print], K Couper, C Ji, CD Deakin, RT Fothergill, JP Nolan, JB Long, JM Mason, F Michelet, C Norman, H Nwankwo, T Quinn, AM Slowther, MA Smyth, KR Starr, A Walker, S Wood, S Bell, G Bradley, M Brown, S Brown, E Burrow, K Charlton, A Claxton Dip, V Dra'gon, C Evans, J Falloon, T Foster, J Kearney, N Lang, M Limmer, A Mellett-Smith, J Miller, C Mills, R Osborne, N Rees, RES Spaight, GL Squires, B Tibbetts, M Waddington, GA Whitley, JV Wiles, J Williams, S Wiltshire, A Wright, R Lall, GD PerkinsFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.