Elsevier

Resuscitation

Volume 83, Issue 1, January 2012, Pages 107-112
Resuscitation

Experimental paper
Pharmacokinetics of intraosseous and central venous drug delivery during cardiopulmonary resuscitation,☆☆

https://doi.org/10.1016/j.resuscitation.2011.07.041Get rights and content

Abstract

We compared the pharmacokinetics of intraosseous (IO) drug delivery via tibia or sternum, with central venous (CV) drug delivery during cardiopulmonary resuscitation (CPR).

Methods

CPR of anesthetized KCl arrest swine was initiated 8 min post arrest. Evans blue and indocyanine green, each were simultaneously injected as a bolus with adrenaline through IO sternal and tibial needles, respectively, n = 7. In second group (n = 6) simultaneous IO sternal and IV central venous (CV) injections were made.

Results

Peak arterial blood concentrations were achieved faster for sternal IO vs. tibial IO administration (53 ± 11 s vs. 107 ± 27 s, p = 0.03). Tibial IO dose delivered was 65% of sternal administration (p = 0.003). Time to peak blood concentration was similar for sternal IO and CV administration (97 ± 17 s vs. 70 ± 12 s, respectively; p = 0.17) with total dose delivered of sternal being 86% of the dose delivered via CV (p = 0.22).

Conclusions

IO drug administrations via either the sternum or tibia were effective during CPR in anesthetized swine. However, IO drug administration via the sternum was significantly faster and delivered a larger dose.

Introduction

Survival from out-of-hospital cardiac arrest depends on a sequence of therapeutic interventions termed the “chain of survival” by the American Heart Association (AHA). This sequence includes rapid access to emergency medical care, cardiopulmonary resuscitation (CPR), defibrillation, advanced care, and post resuscitation techniques such as hypothermia, percutaneous coronary interventions, and implantable cardioverter-defibrilators.1, 2 Unfortunately, survival rates after cardiac arrests are dismal (2.5–10.5%).3, 4, 5 More rapid vascular accesses for drug delivery during CPR may be one way of improving survival.

Intravenous access during CPR can be difficult even for an experienced caregiver. In one study, the median time required to establish an intravenous (IV) line by well-trained paramedics in the field was 2 min for first attempts and 5 min when further attempts were required.6 The overall success rate to establish an IV line in the field for medical emergencies is less than 75%.6, 7, 8 There remains a need for more rapid vascular accesses for drug delivery during CPR may be one way of improving survival. Intravenous access during cardiopulmonary resuscitation (CPR) can be difficult even for an experienced caregiver. Intraosseous vascular (IO) access is an established rapid, safe, and effective alternative for peripheral intravenous drug delivery.8, 9 The American Heart Association and the European Resuscitation Council Guidelines for Pediatric Life Support recommend IO access via the tibia for pediatric patients.12, 13 In the last 10 years, several large bore IO needles for adult patients have become available that use IO access via the sternum, tibia and humerus. These devices have been evaluated in both patients and animals.8, 10, 11 Use of these devices provides rapid access to the systemic circulation during normovolemia.7, 8, 10, 14 However, the effectiveness of IO drug delivery via different anatomical sites during CPR has been under evaluation.

We used a swine model of cardiac arrest to determine the pharmacokinetics of IO delivery of a double dye tracer method during CPR using simultaneous IO injections in the sternum and tibia. We also compared the pharmacokinetics of tracer administration via the sternum vs. central venous IV administration.

Section snippets

Animal preparation

The study protocol was approved by the University of Texas Medical Branch's Institutional Animal Care and Use Committee (IACUC). UTMB animal facilities are accredited by the American Association for the Accreditation of Laboratory Animal Care.

The experimental model was Yorkshire swine (25–35 kg). The night before the experiment food was withheld from the animals, though they had free access to water. Pre sedation was induced the day of the experiment by an intramuscular injection of telazol,

Results

Data on appearance time and dose delivered for all individual animals and groups are presented in figures and tables.

Discussion

To the best of our knowledge the present study is the first to use a double tracer technique to assess effectiveness of simultaneous drug delivery, during CPR into two IO sites.

Overall the study demonstrated that the intraosseous (IO) route is an effective means of delivering drugs during CPR for tibia and sternum IO sites.

Peripheral IV lines are the most commonly used routes for drug delivery by EMS personnel. An absence of venous blood flow and low pressure during cardiac arrest can lengthen

Conclusions

Both tibial and sternal IO routes are an effective means of delivering life saving drugs during CPR. Dye tracers delivered via tibial IO or sternal IO routes of anesthetized swine reached maximal concentrations in the arterial blood during CPR in less than 2 min with both, a faster and a greater dose delivered using the sternum route than with the tibial route. Sternal IO and central venous routes are not different considering pharmacokinetics of tracers during CPR in swine.

Conflict of interest

Dr. Kramer is an inventor on patents for intraosseous technologies and a compensated consultant to Vidacare 2007–2010.

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    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.07.041.

    ☆☆

    Financial support: American Heart Association Texas Affiliate Grant-in-Aid #0455157Y.

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