Effects of tibial and humerus intraosseous and intravenous vasopressin in porcine cardiac arrest model
Keywords:intraosseous, return of spontaneous circulation, pharmacokinetics, resuscitation, hemorrhage, vasopressin
Objective: Compare maximum concentration (Cmax), time to maximum concentration (Tmax), mean serum concentration of vasopressin, return of spontaneous circulation (ROSC), time to ROSC, and odds of survival relative to vasopressin administration by tibial intraosseous (TIO), humerus intraosseous (HIO), and intravenous (IV) routes in a hypovolemic cardiac arrest model.
Design: Prospective, between subjects, randomized experimental design.
Setting: TriService Research Facility.
Subjects: Yorkshire-cross swine (n = 40).
Intervention: Swine were anesthetized, exsanguinated to a Class III hemorrhage, and placed into cardiac arrest. After 2 minutes, cardiopulmonary resuscitation was initiated. After an additional 2 minutes, a dose of 40 units of vasopressin was administered by TIO, HIO, or the IV routes. Blood samples were collected over 4 minutes and analyzed by high-performance liquid chromatography tandem mass spectrometry.
Main Outcome Measurements: ROSC, time to ROSC, Cmax, Tmax, mean concentrations over time, and odds ratio.
Results: There was no significant difference in rate of ROSC or time to ROSC between the TIO, HIO, and IV groups (p > 0.05). The Cmax was significantly higher in the IV group compared to the TIO group (p = 0.015), but no significant difference between the TIO versus HIO or HIO versus IV groups (p > 0.05). The Tmax was significantly shorter for the HIO compared to the TIO group (p = 0.034), but no significant differences between the IV group compared to the TIO or HIO groups (p > 0.05). The odds of survival were higher in the HIO group compared to all other groups.
Conclusion: The TIO and HIO provide rapid and reliable access to administer life-saving medications during cardiac arrest.
CoT ACoS: Advanced Trauma Life Support for Doctors, Student Course Manual. 9th ed. Chicago, IL: American College of Surgeons, 2012.
Kauvar DS, Lefering R, Wade CE: Impact of hemorrhage on trauma outcome: An overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006; 60(6)(suppl): S3-S11.
Kauvar DS, Sarfati MR, Kraiss LW: National trauma databank analysis of mortality and limb loss in isolated lower extremity vascular trauma. J Vasc Surg. 2011; 53(6): 1598-1603.
Peiniger S, Paffrath T, Mutschler M, et al.: The trauma patient in hemorrhagic shock: How is the C-priority addressed between emergency and ICU admission? Scand J Trauma Resusc Emerg Med. 2012; 20: 78.
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.
Callaway CW, Soar J, Aibiki M, et al.: Part 4: Advanced life support: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2015; 132(16)(suppl 1): S84.
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.
Anson JA: Vascular access in resuscitation: Is there a role for the intraosseous route? Anesthesiology. 2014; 120(4): 1015-1031.
Anson JA, Sinz EH, Swick JT: The versatility of intraosseous vascular access in perioperative medicine: A case series. J Clin Anesth. 2015; 27(1): 63-67.
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.
Leidel BA, Kirchhoff C, Bogner V, et al.: Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins. Resuscitation. 2012; 83(1): 40-45.
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.
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.
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.
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.: Effects of epinephrine and vasopressin in a piglet model of prolonged ventricular fibrillation and cardiopulmonary resuscitation. Crit Care Med. 2002; 30(5): 957-962.
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.
Voelckel WG, Lurie KG, Lindner KH, et al.: Vasopressin improves survival after cardiac arrest in hypovolemic shock. Anesth Analg. 2000; 91(3): 627-634.
Wenzel V, Lindner KH, Krismer AC, et al.: Repeated administration of vasopressin but not epinephrine maintains coronary perfusion pressure after early and late administration during prolonged cardiopulmonary resuscitation in pigs. Circulation. 1999; 99(10): 1379-1384.
Hoskins SL, do Nascimento P Jr, Lima RM, et al.: Pharmacokinetics of intraosseous and central venous drug delivery during cardiopulmonary resuscitation. Resuscitation. 2012; 83(1): 107-112.
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.
Johnson D, Giles K, Acuna A, et al.: Effects of tibial intraosseous and IV administration of vasopressin on kinetics and survivability in cardiac arrest. Am J Emerg Med. 2016; 34(3): 429-432.
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.
Hannon JP, Bossone CA, Wade CE: Normal physiological values for conscious pigs used in biomedical research. Lab Animal Sci. 1990; 40(3): 293-298.
Swindle MM: The development of swine models in drug discovery and development. Future Med Chem. 2012; 4(14): 1771-1772.
Swindle MM, Makin A, Herron AJ, et al.: Swine as models in biomedical research and toxicology testing. Vet Pathol. 2012; 49(2): 344-356.
Johnson D, Dial J, Ard J, et al.: Effects of intraosseous and intravenous administration of hextend® on time of administration and hemodynamics in a Swine model. J Spec Oper Med. 2014; 14(1): 79-85.
Butler FK, Holcomb JB, Schreiber MA, et al.: Fluid resuscitation for hemorrhagic shock in Tactical Combat Casualty Care: TCCC guidelines change 14-01 - 2 June 2014. J Spec Oper Med. 2014; 14(3): 13-38.
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.
Hsieh Y, Korfmacher WA: Increasing speed and throughput when using HPLC-MS/MS systems for drug metabolism and pharmacokinetic screening. Curr Drug Metab. 2006; 7(5): 479-489.
Grebe SK, Singh RJ: LC-MS/MS in the clinical laboratory - Where to from here? Clin Biochem Rev. 2011; 32(1): 5-31.
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.
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.
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.
Burgert JM, Austin PN, Johnson A: An evidence-based review of epinephrine administered via the intraosseous route in animal models of cardiac arrest. Mil Med. 2014; 179(1): 99-104.
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.
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