Open Access Open Access  Restricted Access Subscription or Fee Access

Humerus intraosseous administration of epinephrine in normovolemic and hypovolemic porcine model

LTC Robert P. Long, II, PhD, CRNA, LTC Stephanie M. Gardner, DNP, CRNA, James Burgert, DNAP, CRNA, LTC Craig A. Koeller, DVM, DACLAM, AFRL, LTC Joseph O’Sullivan, PhD, CRNA, Dawn Blouin, BS, COL Don Johnson, PhD

Abstract


Objective: Compare the maximum concentration (Cmax), time to maximum concentration (Tmax), mean concentration, rate of return of spontaneous circulation (ROSC), time to ROSC, and odds of ROSC when epinephrine is administered by humerus intraosseous (HIO) compared to intravenous (IV) routes in both a hypovolemic and normovolemic cardiac arrest model.

Design: Prospective, between subjects, randomized experimental study.

Setting: TriService Facility.

Subjects: Twenty-eight adult Yorkshire Swine were randomly assigned to four groups: HIO normovolemia; HIO hypovolemia; IV normovolemia; and IV hypovolemia.

Intervention: Swine were anesthetized. The hypovolemic group was exsanguinated 31 percent of their blood volume. Subjects were placed into arrest. After 2 minutes, cardiopulmonary resuscitation (CPR) was initiated. After another 2 minutes, 1 mg epinephrine was given by IV or HIO routes; blood samples were collected over 4 minutes. Hypovolemic groups received 500 mL of 5 percent albumin following blood sampling. CPR continued until ROSC or for 30 minutes.

Main outcome measures: ROSC, time to ROSC, Cmax, Tmax, mean concentrations over time, odds of ROSC.

Results: Cmax was significantly higher, the Tmax, and the time to ROSC were significantly faster in the HIO normovolemic compared to the HIO hypovolemic group (p < 0.05). All seven in the HIO normovolemic group achieved ROSC compared to three of the HIO hypovolemic group. Odds of ROSC were 19.2 times greater in the HIO normovolemic compared the HIO hypovolemic group.

Conclusion: The HIO is an effective route in a normovolemic model. However, the findings indicate that sufficient blood volume is essential for ROSC in a hypovolemic scenario.


Keywords


cardiac arrest, hemorrhage, intraosseous, epinephrine, shock

Full Text:

PDF

References


Kiyohara K, Kitamura T, Iwami T, et al.: Impact of the Great East Japan earthquake on out-of-hospital cardiac arrest with cardiac origin in non-disaster areas [corrected]. J Epidemiol Community Health. 2015; 69(2): 185-188.

Dobson AJ, Alexander HM, Malcolm JA, et al.: Heart attacks and the Newcastle earthquake. Med J Aust. 1991; 155(11-12): 757-761.

Katsouyanni K, Kogevinas M, Trichopoulos D: Earthquake-related stress and cardiac mortality. Int J Epidemiol. 1986; 15(3): 326-330.

Kloner RA, Leor J, Poole WK, et al.: Population-based analysis of the effect of the Northridge earthquake on cardiac death in Los Angeles County, California. J Am Coll Cardiol. 1997; 30(5): 1174-1180.

Leor J, Poole WK, Kloner RA: Sudden cardiac death triggered by an earthquake. N Engl J Med. 1996; 334(7): 413-419.

Suzuki S, Sakamoto S, Koide M, et al.: Hanshin-Awaji earthquake as a trigger for acute myocardial infarction. Am Heart J. 1997; 134(5, pt 1): 974-977.

Trichopoulos D, Katsouyanni K, Zavitsanos X, et al.: Psychological stress and fatal heart attack: The Athens (1981) earthquake natural experiment. Lancet. 1983; 1(8322): 441-444.

Planas JH, Waseem M: Trauma, primary survey. StatPearls. Treasure Island, FL: StatPearls Publishing, 2018.

Ruseckaite R, McQuilten ZK, Oldroyd JC, et al.: Descriptive characteristics and in-hospital mortality of critically bleeding patients requiring massive transfusion: Results from the Australian and New Zealand Massive Transfusion Registry. Vox Sang. 2017; 112(3): 240-248.

Saar S, Lomp A, Laos J, et al.: Population-based autopsy study of traumatic fatalities. World J Surg. 2017; 41(7): 1790-1795.

Anson JA: Vascular access in resuscitation: Is there a role for the intraosseous route? Anesthesiology. 2014; 120(4): 1015-1031.

Burgert J, Gegel B, Loughren M, et al.: Comparison of tibial intraosseous, sternal intraosseous, and intravenous routes of administration on pharmacokinetics of epinephrine during cardiac arrest: A pilot study. AANA J. 2012; 80(4)(suppl): S6-S10.

Neumar RW, Otto CW, Link MS, et al.: Part 8: Adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010; 122(18)(suppl 3): S729-S767.

Larsen MP, Eisenberg MS, Cummins RO, et al.: Predicting survival from out-of-hospital cardiac arrest: A graphic model. Ann Emerg Med. 1993; 22(11): 1652-1658.

Coute RA, Panchal AR, Mader TJ, et al.: National Institutes of Health-funded cardiac arrest research: A 10-year trend analysis. J Am Heart Assoc. 2017; 6(7): 1-6.

Morrison LJ, Deakin CD, Morley PT, et al.: Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation. 2010; 122(16)(suppl 2): S345-S421.

Link MS, Berkow LC, Kudenchuk PJ, et al.: Part 7: Adult advanced cardiovascular life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015; 132(18)(suppl 2): S444-S464.

Lewis P, Wright C: Saving the critically injured trauma patient: A retrospective analysis of 1000 uses of intraosseous access. Emerg Med J. 2015; 32(6): 463-467.

Wright C, Lewis PE: Re: Saving the critically injured trauma patient. Emerg Med J. 2015; 32(11): 903-904.

Beaumont LD, Baragchizadeh A, Johnson C, et al.: Effects of tibial and humerus intraosseous administration of epinephrine in a cardiac arrest swine model. Am J Disaster Med. 2016; 11(4): 243-251.

Yost J, Baldwin P, Bellenger S, et al.: The pharmacokinetics of intraosseous atropine in hypovolemic swine. Am J Disaster Med. 2015; 10(3): 217-222.

Cornell M, Kelbaugh J, Todd B, et al.: Pharmacokinetics of sternal intraossesous atropine administration in normovolemic and hypovolemic swine. Am J Disaster Med. 2016; 11(4): 233-236.

Loughren M, Banks S, Naluan C, et al.: Onset and duration of intravenous and intraosseous rocuronium in swine. West J Emerg Med. 2014; 15(2): 241-245.

Loughren MJ, Kilbourn J, Worth K, et al.: Comparison of muscle paralysis after intravenous and intraosseous administration of succinylcholine in Swine. J Spec Oper Med. 2014; 14(2): 35-37.

Nemeth M, Williams GN 3rd, Prichard D, et al.: Onset and duration of intravenous and intraosseous rocuronium in hypovolemic swine. Am J Disaster Med. 2016; 11(4): 279-282.

Wimmer MH, Heffner K, Smithers M, et al.: The comparison of humeral intraosseous and intravenous administration of vasopressin on return of spontaneous circulation and pharmacokinetics in a hypovolemic cardiac arrest swine model. Am J Disaster Med. 2016; 11(4): 237-242.

Von Hoff DD, Kuhn JG, Burris HA 3rd, et al.: Does intraosseous equal intravenous? A pharmacokinetic study. Am J Emerg Med. 2008; 26(1): 31-38.

Burgert JM: A primer on intraosseous access: History, clinical considerations, and current devices. Am J Disaster Med. 2016; 11(3): 167-173.

Burgert JM: Intraosseous vascular access in disasters and mass casualty events: A review of the literature. Am J Disaster Med. 2016; 11(3): 149-166.

EEC Committee SaTFotAHA: Guidelines for resuscitation and emergency cardiovasuclar care. Circulation. 2010; 122(18)(suppl 3): S742.

Voelckel WG, Lurie KG, McKnite S, et al.: Comparison of epinephrine with vasopressin on bone marrow blood flow in an animal model of hypovolemic shock and subsequent cardiac arrest. Crit Care Med. 2001; 29(8): 1587-1592.

Wong MR, Reggio MJ, Morocho FR, et al.: Effects of intraosseous epinephrine in a cardiac arrest swine model. J Surg Res. 2016; 201(2): 327-333.

Burgert JM, Johnson AD, Garcia-Blanco J, et al.: The effects of proximal and distal routes of intraosseous epinephrine administration on short-term resuscitative outcome measures in an adult swine model of ventricular fibrillation: A randomized controlled study. Am J Emerg Med. 2016; 34(1): 49-53.

Burgert J, Johnson D, Blanco J, et al.: A randomized controlled study of the pharmacokinetics and resuscitative effects of intraosseous vasopressin in an adult swine model of ventricular fibrillation. Prehosp Disaster Med. 2016; 107(3)(suppl 2): 38.

National Research Council (US) Committee for the Update of the Guide for the Care and Use of Laboratory Animals: Guide for the Care and Use of Laboratory Animals. 8th ed. Washington, DC: The National Academies Press, 2011.

Paquette S, Gordon C, Bradtmiller B: Anthropometric Survey (ANSUR) II Pilot Study: Methods and Summary Statistics. Natick, MA: US Army Natick Soldier Research, Development and Engineering Center, 2009.

Petitpas F, Guenezan J, Vendeuvre T, et al.: Use of intra-osseous access in adults: A systematic review. Crit Care. 2016; 20: 102.

Coles DR, Cooper KE, Mottram RF, et al.: The source of blood samples withdrawn from deep forearm veins via catheters passed upstream from the median cubital vein. J Physiol. 1958; 142(2): 323-328.

Karnabatidis D, Katsanos K, Diamantopoulos A, et al.: Transauricular arterial or venous access for cardiovascular experimental protocols in animals. J Vasc Interv Radiol. 2006; 17(11, pt 1): 1803-1811.

Burgert JM, Johnson AD, Garcia-Blanco JC, et al.: An effective and reproducible model of ventricular fibrillation in crossbred Yorkshire Swine (Sus scrofa) for use in physiologic research. Comp Med. 2015; 65(5): 444-447.

Moraes JM, Vane MF, Rodrigues Dde F, et al.: Effects of catecholamines on volemic replacement with saline solution and the impact on heart rate variability in rabbits subjected to hemorrhage. A study by spectral analysis. Acta Cir Bras. 2014; 29(11): 703-710.

Tsai MH, Huang HC, Peng YS, et al.: Critical illness-related corticosteroid insufficiency in cirrhotic patients with acute gastroesophageal variceal bleeding: Risk factors and association with outcome. Crit Care Med. 2014; 42(12): 2546-2555.

Johnson D, Garcia-Blanco J, Burgert J, et al.: Effects of humeral intraosseous versus intravenous epinephrine on pharmacokinetics and return of spontaneous circulation in a porcine cardiac arrest model: A randomized control trial. Ann Med Surg (Lond). 2015; 4(3): 306-310.

Fulkerson J, Lowe R, Anderson T, et al.: Effects of intraosseous tibial vs. intravenous vasopressin in a hypovolemic cardiac arrest model. West J Emerg Med. 2016; 17(2): 222-228.

Hampton K, Wang E, Argame JI, et al.: The effects of tibial intraosseous versus intravenous amiodarone administration in a hypovolemic cardiac arrest procine model. Am J Disaster Med. 2016; 11(4): 253-260.

Holloway CM, Jurina CS, Orszag CJ, et al.: Effects of humerus intraosseous versus intravenous amiodarone administration in a hypovolemic porcine model. Am J Disaster Med. 2016; 11(4): 261-269.

Smith S, Borgkvist B, Kist T, et al.: The effects of sternal intraosseous and intravenous administration of amiodarone in a hypovolemic swine cardiac arrest model. Am J Disaster Med. 2016; 11(4): 271-277.

Wenzel V, Lindner KH, Augenstein S, et al.: Intraosseous vasopressin improves coronary perfusion pressure rapidly during cardiopulmonary resuscitation in pigs. Crit Care Med. 1999; 27(8): 1565-1569.

Levitan RM, Bortle CD, Snyder TA, et al.: Use of a battery-operated needle driver for intraosseous access by novice users: Skill acquisition with cadavers. Ann Emerg Med. 2009; 54(5): 692-694.

Santos D, Carron PN, Yersin B, et al.: EZ-IO intraosseous device implementation in a pre-hospital emergency service: A prospective study and review of the literature. Resuscitation. 2013; 84(4): 440-445.

Paxton JH, Knuth TE, Klausner HA: Proximal humerus intraosseous infusion: A preferred emergency venous access. J Trauma. 2009; 67(3): 606-611.

Malkiewicz A, Dziedzic M: Bone marrow reconversion—Imaging of physiological changes in bone marrow. Pol J Radiol. 2012; 77(4): 45-50.

Hartholt KA, van Lieshout EM, Thies WC, et al.: Intraosseous devices: A randomized controlled trial comparing three intraosseous devices. Prehosp Emerg Care. 2010; 14(1): 6-13.

Swindle MM, Makin A, Herron AJ, et al.: Swine as models in biomedical research and toxicology testing. Vet Pathol. 2012; 49(2): 344-356.

Walcott GP, Kroll MW, Ideker RE: Ventricular fibrillation: Are swine a sensitive species? J Interv Card Electrophysiol. 2015; 42(2): 83-89.

Niemann JT, Rosborough JP, Youngquist S, et al.: Is all ventricular fibrillation the same? A comparison of ischemically induced with electrically induced ventricular fibrillation in a porcine cardiac arrest and resuscitation model. Crit Care Med. 2007; 35(5): 1356-1361.

Kroll MW, Fish RM, Calkins H, et al.: Defibrillation success rates for electrically-induced fibrillation: Hair of the dog. Conf Proc IEEE Eng Med Biol Soc. 2012; 2012: 689-693.

Ngo AS, Oh JJ, Chen Y, et al.: Intraosseous vascular access in adults using the EZ-IO in an emergency department. Int J Emerg Med. 2009; 2(3): 155-160.




DOI: http://dx.doi.org/10.5055/ajdm.2018.0291

Refbacks

  • There are currently no refbacks.
This site uses cookies to maintain session information critical to the user's experience and environment on this system. Click "Accept Cookies" to continue.
For more details please visit our privacy statement at: Privacy & GDPR