Intraosseous drug administration is associated with lower survival in out-of-hospital cardiac arrest
Hamam M, Miller J, France J, Otero R, Swor R, Paxton JH, O'Neil BJ, Brent C, Neumar RW, Dunne R, Klausner HA, and Milzman D. Intraosseous drug administration is associated with lower survival in out-of-hospital cardiac arrest. Acad Emerg Med 2019; 26:S155-S156.
Acad Emerg Med
Background: Recent data has questioned the efficacy of intraosseous (IO) route of drug administration in out-of-hospital cardiac arrest (OHCA) resuscitation. Our primary aim was to test if pre-hospital IO versus intravenous (IV) drug administration was associated with lower rates of return of spontaneous circulation (ROSC) and survival to hospital discharge in OHCA. Methods: Using data from the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) database, we analyzed all OHCA in the 3 most populous counties of Michigan over 2 years (population 3.8 million). We excluded patients that did not receive any IV/IO access or parenteral drugs in their resuscitation. Pre-hospital protocols designated tibial IO placement. We tested the association between route of drug administration and rates of ROSC and survival using a multivariate logistic regression model adjusting for age, gender, initial rhythm, bystander CPR, witnessed status, endotracheal intubation, time to EMS response, and location of arrest. We also performed sensitivity analyses limiting the cohort to non-nursing home OHCA. Results: Of 10,626 OHCA patients, we analyzed 6,869 that received parenteral drugs during resuscitation (37.8% by IO and 62.2% by IV route). Patients with IO drug administration were more often female, had bystander CPR, had a non-shockable rhythm, had an unwitnessed arrest, and were in a nursing home. There was no difference in time to EMS response between patients with IO vs. IV drug administration. Unadjusted outcomes were lower in patients with IO vs. IV access: 18.3% vs. 23.8% for ROSC (p<0.001), 3.2% vs. 7.6% for survival to hospital discharge (p<0.001), and 2.0% vs. 5.8% for favorable neurological function (p<0.001). After adjustment, IO route remained associated with lower rates of sustained ROSC (OR 0.72, 95% CI 0.63 - 0.81, p<0.001), hospital survival (OR 0.48, 95% CI 0.37 - 0.62, p<0.001), and favorable neurological function (OR 0.42, 95% CI 0.30 - 0.57, p<0.001). Sensitivity analyses had identical findings. Conclusion: In this cohort of OHCA with a large proportion of IO placement, the IO route of drug administration was associated with half the odds of survival after adjusting for major pre-hospital covariates.