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Intraosseous or Intravenous Vascular Access for Out-of-Hospital Cardiac Arrest
Abstract
Background
Out-of-hospital cardiac arrest is a leading cause of death worldwide. Establishing vascular access is critical for administering guideline-recommended drugs during cardiopulmonary resuscitation. Both the intraosseous route and the intravenous route are used routinely, but their comparative effectiveness remains unclear.
Methods
We conducted a randomized clinical trial to compare the effectiveness of initial attempts at intraosseous or intravenous vascular access in adults who had nontraumatic out-of-hospital cardiac arrest. The primary outcome was a sustained return of spontaneous circulation. Key secondary outcomes were survival at 30 days and survival at 30 days with a favorable neurologic outcome, defined by a score of 0 to 3 on the modified Rankin scale (scores range from 0 to 6, with higher scores indicating greater disability).
Results
Among 1506 patients who underwent randomization, 1479 were included in the primary analysis (731 in the intraosseous-access group and 748 in the intravenous-access group). The successful establishment of vascular access within two attempts occurred in 669 patients (92%) assigned to the intraosseous-access group and in 595 patients (80%) assigned to the intravenous-access group. Sustained return of spontaneous circulation occurred in 221 patients (30%) in the intraosseous-access group and in 214 patients (29%) in the intravenous-access group (risk ratio, 1.06; 95% confidence interval [CI], 0.90 to 1.24; P=0.49). At 30 days, 85 patients (12%) in the intraosseous-access group and 75 patients (10%) in the intravenous-access group were alive (risk ratio, 1.16; 95% CI, 0.87 to 1.56); a favorable neurologic outcome at 30 days occurred in 67 patients (9%) and 59 patients (8%), respectively (risk ratio, 1.16; 95% CI, 0.83 to 1.62). Prespecified adverse events were uncommon.
Conclusions
There was no significant difference in sustained return of spontaneous circulation between initial intraosseous and intravenous vascular access in adults who had out-of-hospital cardiac arrest. (Funded by the Novo Nordisk Foundation and others; IVIO EU Clinical Trials Register number, 2022-500744-38-00; ClinicalTrials.gov number, NCT05205031.)
Notes
This article was published on October 31, 2024, at NEJM.org.
A data sharing statement provided by the authors is available with the full text of this article at NEJM.org.
Supported by the Novo Nordisk Foundation, the Tryg Foundation, Aarhus University, the Independent Research Fund Denmark, and Snedkermester Sophus Jacobsen og Hustru Astrid Jacobsens Fond through the Danish Heart Foundation.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
We thank the clinical teams for facilitating the enrollment of patients; Jesper Kjærgaard, M.D., Ph.D., D.M.Sc., Markus Skrifvars, M.D., Ph.D., and Michael W. Donnino, M.D., for participating on the independent data monitoring committee; and Torben Anders Kløjgaard, M.Sc., for providing screening data.
Supplementary Material
Information & Authors
Information
Published In
New England Journal of Medicine
Copyright
Copyright © 2024 Massachusetts Medical Society. All rights reserved.
For personal use only. Any commercial reuse of NEJM Group content requires permission.
History
Published online: October 31, 2024
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Authors
Affiliations
From Prehospital Emergency Medical Services, Central Denmark Region (M.F.V., A.L.P., A.H.P., S.W., L.W.F., C.M., K.B.W., A.B., T.H.D., L.K.R., L.R.M., M.L.L., T.E., A.G.N., C.R., L.W.A.), the Department of Clinical Medicine, Aarhus University (M.F.V., A.G., C.J.T., S.C., L.W.A.), and the Departments of Anesthesiology and Intensive Care (A.G., M.J.H., T.H.D., S.C., C.G.N., B.S., L.W.A.), Cardiology (C.J.T.), and Radiology (E.K.), Aarhus University Hospital, Aarhus, the Department of Anesthesiology and Intensive Care, Aalborg University Hospital (T.L.K., F.M.N.), the Center for Prehospital and Emergency Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital (E.F.C.), and Emergency Medical Services, North Denmark Region (P.B.), Aalborg, the Prehospital Research Unit (S.M., P.M.H.) and Emergency Medical Services (J.H.H., M.B., L.-G.R.N., M.P., G.K.-A., P.M.H.), Region of Southern Denmark, the Department of Anesthesiology and Intensive Care, Odense University Hospital (J.H.H., M.B.), and the Department of Regional Health Research, University of Southern Denmark (A.C.B.), Odense, the Departments of Cardiology (F.F.) and of Anesthesiology and Intensive Care (L.R.), Copenhagen University Hospital, Gentofte Copenhagen University Hospital–Emergency Medical Services, Ballerup (F.F., J.W.B., H.A., S.H., T.H.F.), the Department of Clinical Medicine, University of Copenhagen (F.F., H.C.C., L.R., M.K.), and the Department of Cardiology, the Heart Center, Copenhagen University Hospital, Rigshospitalet (L.E.R.O., S.L.D.H.), Copenhagen, the Prehospital Center, Region Zealand, Næstved (H.C.C.), the Department of Anesthesiology and Intensive Care, Gødstrup Regional Hospital, Gødstrup (L.K.R.), the Department of Anesthesiology and Intensive Care, Randers Regional Hospital, Randers (L.R.M., T.E.), the Department of Anesthesiology and Intensive Care, Viborg Regional Hospital, Viborg (A.G.N.), the Elective Surgery Center, Silkeborg Regional Hospital, Silkeborg (C.R.), the Department of Anesthesiology and Intensive Care, University Hospital of Southern Denmark, Esbjerg and Grindsted, Esbjerg (L.-G.R.N.), the Department of Anesthesiology and Intensive Care, University Hospital of Southern Denmark, Kolding (M.P., A.C.B.), the Department of Anesthesiology and Intensive Care, University Hospital of Southern Denmark, Aabenraa (G.K.-A.), the Department of Anesthesiology and Intensive Care, Svendborg Hospital, Svendborg (P.M.H.), the Department of Anesthesiology and Intensive Care, Copenhagen University Hospital, Herlev (H.A.), the Department of Anesthesiology and Intensive Care, Copenhagen University Hospital–North Zealand, Hillerød (S.H.), the Department of Anesthesiology and Intensive Care, Zealand University Hospital, Køge (J.U.H.B.), the Department of Anesthesiology and Intensive Care, Nykøbing Falster Hospital, Nykøbing Falster (K.J.), the Department of Anesthesiology and Intensive Care, Holbæk Hospital, Holbæk (M.K.), and the Department of Anesthesiology and Intensive Care, Slagelse Hospital, Slagelse (M.S.) — all in Denmark.
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- The Way to a Patient’s Heart — Vascular Access in Cardiac Arrest, New England Journal of Medicine, 0, 0, (undefined)./doi/full/10.1056/NEJMe2412901
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