Saturday, January 27, 2018

IV vs IO in OHCA

R.E.B.E.L.EM - January 25, 2018 
Article: Kawano T et al. Intraosseous vascular access is associated with lower survival and neurologic recovery among patients with out-of-hospital cardiac arrest. Ann Emerg Med 2018. PMID: 29310869
"Clinical Question: Is intraosseous access associated with lower rates of good neurologic outcomes after cardiac arrest in comparison to intravenous access?
Background: Placement of vascular access for administration of resuscitation drugs and fluids is a common procedure in the management of out of hospital cardiac arrest (OHCA). While intravenous (IV) placement has been the standard approach for decades, intraosseous (IO) access is rapid and safe and may be the preferred approach due to fact that the bone marrow does not collapse during shock states as peripheral veins often do. Despite it’s advantages, there are concerns about IO placement because of the potential for drugs to pool in the marrow and not circulate. Prior studies have shown an association with tibial IO placement and decreased rate of ROSC though no association with worse neurologic outcomes (Feinstein 2017).
Authors Conclusions:
“In adult out-of-hospital cardiac arrest patients, intraosseous vascular access was associated with poorer neurologic outcomes than intravenous access.”
Our Conclusions: This study demonstrates an association only between IO access and worse neurologic outcomes. However, the study is rife with bias secondary to it’s design and thus, cannot be used to advise clinical practice. A well-done, randomized trial is needed.
Potential to Impact Current Practice: This study should not impact clinical practice. If vascular access is desired in an OHCA patient, the most rapid technique should be used and this will be dependent on the provider. Additionally, it should be stressed that obtaining access is not a critical step in OHCA management as no medication has been shown to improve meaningful outcomes (i.e. neurologically intact survival)
Bottom Line: This study should not influence providers to select one vascular access method over another in the resuscitation of OHCA. If vascular access is desired, use the most rapid approach."