An Evidence-Based Review of Epinephrine Administered via the Intraosseous Route in Animal Models of Cardiac Arrest

Military medicine 01/2014; 179(1):99-104. DOI: 10.7205/MILMED-D-13-00231
Source: PubMed


Intraosseous (IO) access, enabling the rapid administration of epinephrine during cardiac arrest (CA), is crucial in promoting optimal postresuscitation outcomes in patients with poor vascular access. There is a question whether IO-administered epinephrine is equivalent to intravenously administered epinephrine during CA.
The question guiding this evidence-based review was as follows: in adults suffering CA given epinephrine via the IO route, what is the resulting serum concentration of the drug compared to when administered intravenously? A search was conducted and the evidence appraised and leveled.
Four animal studies met the inclusion criteria. The sources showed no definitive evidence supporting equivalence between intravenous and IO epinephrine administered during CA. Intravenously administered epinephrine provides increased and faster appearing serum concentrations than IO-administered epinephrine. Evidence indicated epinephrine given via the sternal IO route more closely approaches equivalence with intravenously administered epinephrine than when administered by the tibial IO route.
The clinician should consider using proximal IO infusion sites such as the sternum or humerus when administering advanced cardiac life support drugs to rapidly achieve maximal therapeutic concentrations. Further studies are needed to determine the differences seen when epinephrine is administered by these routes during CA.

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Available from: Don Johnson, Nov 14, 2015
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    ABSTRACT: Introduction: It is unknown if the anatomical distance of intraosseous (IO) epinephrine injection from the heart affects resuscitative outcome. The purpose of this study was to explore the relationships between the anatomical distance of IO epinephrine injection and measures of resuscitative outcome in an adult swine model of ventricular fibrillation (VF). Methods: Thirty-two Yorkshire-cross swine (60-80 kg) were randomly assigned to four groups: humeral IO (HIO), tibial IO (TIO), IV with defibrillation and epinephrine, and IV control: with defibrillation but no epinephrine. Ventricular fibrillation was induced. Swine remained in VF for 4 minutes prior to mechanical chest compressions. After 6 minutes in VF, swine were defibrillated and epinephrine (0.01 mg/kg) administered by group assignment. Defibrillation was repeated every 2 minutes. Epinephrine was repeated every 4 minutes. Interventions continued until return of spontaneous circulation (ROSC) or 26 post-arrest minutes elapsed. Swine achieving ROSC were observed for 30 minutes post-ROSC. Results: There were no significant differences between the HIO, TIO, and IV groups relative to the occurrence of ROSC (P > .05 in all cases), 30-minute post-ROSC survival (P > .05 in all cases), and time to ROSC (P = .43). There were significant differences between the HIO, TIO, and IV groups compared to the control group relative to the occurrence of ROSC (P = .02, .01, and .007 respectively), and 30 minute post-ROSC survival (P = .05, .03, and .007, respectively). Conclusion: The anatomical distance of IO epinephrine injection from the heart did not affect short-term measures of resuscitative outcome in an adult swine model of VF including the occurrence of ROSC, 30 minute post-ROSC survival, and time to ROSC. Rapidly administered epinephrine, irrespective of route of administration, increased the chance ROSC and survival to 30 minutes post-ROSC would occur in this study.
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    ABSTRACT: Cardiopulmonary Resuscitation (CPR), defibrillation, and epinephrine administration are pillars of advanced cardiac life support (ACLS). Intraosseous (IO) access is an alternative route for epinephrine administration when intravenous (IV) access is unobtainable. Previous studies indicate the pharmacokinetics of epinephrine administration via IO and IV routes differ, but it is not known if the difference influences return of spontaneous circulation (ROSC). The purpose of this prospective, experimental study was to determine the effects of humeral IO (HIO) and IV epinephrine administration during cardiac arrest on pharmacokinetics, ROSC, and odds of survival. Swine (N = 21) were randomized into 3 groups: humeral IO (HIO), peripheral IV (IV) and CPR/defibrillation control. Cardiac arrest was induced under general anesthesia. The swine remained in arrest for 2 min without intervention. Chest compressions were initiated and continued for 2 min. Epinephrine was administered and serial blood samples collected for pharmacokinetic analysis over 4 min. Defibrillation and epinephrine administration proceeded according to ACLS guidelines continuing for 20 min or until ROSC. Seven HIO swine, 4 IV swine, and no control swine had ROSC. There were no significant differences in ROSC, maximum concentration; except at 30 s, and time-to-concentration-maximum between the HIO and IV groups. Significant differences existed between the experimental groups and the control. The HIO delivers a higher concentration of epinephrine than the IV route at 30 s which may be a survival advantage. Clinicians may consider using the IO route to administer epinephrine during CA when there is no preexisting IV access or when IV access is unobtainable.
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    No preview · Article · Dec 2015