Comparison of the effects of sternal and tibial intraosseous administered resuscitative drugs on return of spontaneous circulation in a swine model of cardiac arrest
Keywords:amiodarone, epinephrine, intraosseous, resuscitation, return of spontaneous circulation, vasopressin
Objective: Compare vasopressin, amiodarone, and epinephrine administration by sternal intraosseous (SIO), tibial intraosseous (TIO), and intravenous (IV) routes in a swine model of cardiac arrest.
Design: Prospective, randomized, between subjects, experimental design.
Subjects: Male Yorkshire-cross swine (N = 35), seven per group.
Intervention: Swine were randomized to SIO, TIO, IV, cardiopulmonary resuscitation (CPR) with defibrillation, or CPR-only groups. Ventricular fibrillation (VF) was induced under general anesthesia. Mechanical CPR began 2 minutes postarrest. Vasopressin (40 U) was administered to the SIO, TIO, and IV groups 4 minutes postarrest. Defibrillation was performed and amiodarone (300 mg) was administered 6 minutes postarrest. Defibrillation was repeated, and epinephrine (1 mg) was administered 10 minutes postarrest. Defibrillation was repeated every 2 minutes and epinephrine repeated every 4 minutes until return of spontaneous circulation (ROSC) or 26 postarrest minutes elapsed.
Main Outcome Measures: Rate of ROSC, time to ROSC, and odds of ROSC.
Results: There were no significant differences in rate of ROSC between the SIO and TIO (p = 0.22) or IV groups (p = 1.0). Time to ROSC was five times less in the SIO group than the TIO group (p = 0.003) but not compared to IV (p = 0.125). Time to ROSC in the IV group was significantly less than the TIO group (p = 0.04). Odds of ROSC for the SIO group were five times higher compared to the TIO group but same as IV. Odds of ROSC in the IV group were higher than the TIO group.
Conclusion: There was a statistically significant delay in the time to ROSC and a clinically significant difference in odds of ROSC when resuscitative drugs, including lipophilic amiodarone, were administered by the TIO route compared to the SIO and IV routes in a swine model of sudden cardiac arrest. Further investigations are warranted to isolate the mechanism behind these findings.
Mozaffarian D, Benjamin EJ, Go AS, et al.: Heart disease and stroke statistics—2015 update. Rep Am Heart Assoc. 2015; 131(4): e29-e322.
Chan PS, McNally B, Tang F, et al.: Recent trends in survival from out-of-hospital cardiac arrest in the United States. Circulation. 2014; 130(21): 1876-1882.
Marijon E, Uy-Evanado A, Dumas F, et al.: Warning symptoms are associated with survival from sudden cardiac arrest. Ann Intern Med. 2016; 164(1): 23-29.
Dobson AJ, Alexander HM, Malcolm JA, et al.: Heart attacks and the Newcastle earthquake. Med J Aust. 1991; 155(11-12): 757-761.
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): 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.
Layek A, Maitra S, Pal S, et al.: Efficacy of vasopressin during cardio-pulmonary resuscitation in adult patients: A meta-analysis. Resuscitation. 2014; 85(7): 855-863.
Donnino MW, Salciccioli JD, Howell MD, et al.: Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: Retrospective analysis of large in-hospital data registry. BMJ. 2014; 348: g3028.
Stroumpoulis K, Xanthos T, Rokas G, et al.: Vasopressin and epinephrine in the treatment of cardiac arrest: An experimental study. Crit Care. 2008; 12(2): R40-R40.
Soar J, Nolan JP, Bottiger BW, et al.: European resuscitation council guidelines for resuscitation 2015: Section 3. Adult advanced life support. Resuscitation. 2015; 95: 100-147.
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.
Wenzel V, Krismer AC, Arntz HR, et al.: A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med. 2004; 350(2): 105-113.
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.
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.
Mentzelopoulos SD, Zakynthinos SG, Siempos I, et al.: Vasopressin for cardiac arrest: Meta-analysis of randomized controlled trials. Resuscitation. 2012; 83(1): 32-39.
Van Herendael H, Dorian P: Amiodarone for the treatment and prevention of ventricular fibrillation and ventricular tachycardia. Vasc Health Risk Manag. 2010; 6: 465-472.
Connolly SJ: Evidence-based analysis of amiodarone efficacy and safety. Circulation. 1999; 100(19): 2025-2034.
Dabrowska A, Telec W: [New guidelines of Basic and Advanced Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (ECC) American Heart Association (AHA)]. Wiad Lek. 2011; 64(2): 127-131.
Chapleau W, Al-khatib J, Haskin D. Advanced trauma life support (ATLS(R)): The ninth edition. J Trauma Acute Care Surg. 2013; 74(5): 1363-1366.
Care CoTCC: Tactical Combat Casualty Care Guidelines. 2014. Available at http://www.usaisr.amedd.army.mil/pdfs/TCCC_Guidelines_140602.pdf. Accessed August 29, 2016.
Blebea JS, Houseni M, Torigian DA, et al.: Structural and functional imaging of normal bone marrow and evaluation of its age-related changes. Semin Nucl Med. 2007; 37(3): 185-194.
Malkiewicz A, Dziedzic M: Bone marrow reconversion—Imaging of physiological changes in bone marrow. Pol J Radiol. 2012; 77(4): 45-50.
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: 74-75.
National Research Council, Committee for the Update of the Guide for the Care and Use of Laboratory Animals, Institute for Laboratory Animal Research: Guide for the Care and Use of Laboratory Animals. Washington, DC: National Academies Press, 2011.
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.
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.
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.
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. 2015; 4(3): 306-310.
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.
Pasley J, Miller CH, DuBose JJ, et al.: Intraosseous infusion rates under high pressure: A cadaveric comparison of anatomic sites. J Trauma Acute Care Surg. 2015; 78(2): 295-299.
Rohm I, Ratka J, Pistulli R, et al.: Impact of systemic normobaric short-term hypoxia on pro-inflammatory and anti-inflammatory cytokines in healthy volunteers. Clin Lab. 2015; 61(8): 1053-1059.
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.
Lelovas PP, Kostomitsopoulos NG, Xanthos TT: A comparative anatomic and physiologic overview of the porcine heart. J Am Assoc Lab Anim Sci. 2014; 53(5): 432-438.
How to Cite
Copyright 2007-2023, Weston Medical Publishing, LLC
All Rights Reserved