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Point | Counterpoint – IO Beats IV Epinephrine for OHCA

March 10, 2020


Written by Aaron Lacy

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In patients who suffered out-of-hospital cardiac arrest (OHCA) there was no significant difference in treatment effect on ROSC at hospital handover between those who received administration of epinephrine or placebo via IV or IO.

Why does this matter?
While the literature has been back and forth on epinephrine administration in OHCA, PARAMEDIC2 showed increased survival at 30-days in those given epinephrine versus placebo. But does the administration route (IV versus IO) matter? Any difference found would have important implications for pre-hospital protocols.

Let me try to get an IV just one more time…
This was a secondary analysis of PARAMEDIC2 data comparing outcomes when given either epinephrine or placebo (0.9% NS) via IV or IO lines.  30.7% (n = 1116) and 30.4% (n = 1121) of patients randomized to epinephrine and placebo, respectively, received their medications via IO lines. Both the primary outcome, survival at 30 days, and one secondary outcome, favorable neurological outcome at hospital discharge, had no statistical difference in adjusted odds ratios (aOR) between IV and IO groups. Another secondary outcome, ROSC at hospital handoff, was statistically similar between IV [aOR 4.07 (95% CI 3.42-4.85)] and IO [3.98 (95% CI 2.86-5.53)] groups. It is also important to note that pre-hospital protocol in this study, which is most likely generalizable, was to use the IO route only after failed or predicted difficult IV access.

Overall, first attempt success rate was higher in IO versus IV access (94.8% versus 81.6%, P <0.01). This study has me thinking, in the same way that the bougie is gaining traction as a first-pass device for all airways attempts, what impact would it have to go straight to IO in OHCA, regardless of difficulty in obtaining IV access?

Editor’s note: Although there was no statistical difference in the aORs for IV vs IO for the primary outcome of 30-day survival, it is interesting that the absolute percentage was higher for IV. There is no way to know this with certainty without a RCT. Please see tomorrow’s post as we discuss this further. – Clay Smith

From cited article

Intraosseous versus intravenous administration of adrenaline in patients with out-of-hospital cardiac arrest: a secondary analysis of the PARAMEDIC2 placebo-controlled trial.  Intensive Care Med. 2020 Jan 30. doi: 10.1007/s00134-019-05920-7. [Epub ahead of print]

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What are your thoughts?