Deathmatch : Central Access Versus Intraosseous Access. FIGHT!

In the January edition of Resuscitation, is a prospective observational study, investigating the success rates on first attempt and procedure times of IO access, aginst central venous access in adults with difficult peripheral veins in the context of acute resuscitation - either traumatic or medical, in a level 1 trauma centre.

And what did they find, I hear you ask?? Well, it comes as little surprise that IO vascular access was found to be rapid, and reliable in the context of acute resuscitation, with a higher success rate on first attempt, and a lower procedure time when compared to  land mark based CVC. 

INTRODUCTION:

Current European Resuscitation Council (ERC) guidelines recommend intraosseous (IO)vascular access, if intravenous (IV) access is not readily available. Because central venous catheterisation (CVC) is an established alternative for in-hospital resuscitation, we compared IO access versus landmark-based CVC in adults with difficult peripheral veins.

METHODS:

In this prospective observational study we investigated success rates on first attempt and procedure times of IO access versus central venous catheterisation (CVC) in adults (≥18 years of age) withinaccessible peripheral veins under trauma or medical resuscitation in a level I trauma centre emergencydepartment.

RESULTS:

Forty consecutive adults under resuscitation were analysed, each receiving IO access and CVC simultaneously. Success rates on first attempt were significantly higher for IO cannulation than CVC (85%versus 60%, p=0.024) and procedure times were significantly lower for IO access compared to CVC (2.0versus 8.0min, p<0.001). As for complications, failure of IO access was observed in 6 patients, while 2 or more attempts of CVC were necessary in 16 patients. No other relevant complications like infection, bleeding or pneumothorax were observed.

CONCLUSIONS:

IO vascular access is a reliable bridging method to gain vascular access for in-hospital adult patients under resuscitation with difficult peripheral veins. Moreover, IO access is more efficacious with a higher success rate on first attempt and a lower procedure time compared to landmark-based CVC.

There is an increasing body of evidence, supporting the role of intraosseous access in the acute resuscitation situation, where tradiotional IV access is problematic (e.g the severe burns patient). What are you currently doing in your department?

Resuscitation. 2012 Jan;83(1):40-5. Epub 2011 Sep 3.

Slightly Funnier than Placebo - ZDoggMD

You all thought it was over with Weingart taking the number one slot. Oh contraire mes amis. After finishing harping on about my favourite ED critical care blogs over the last few days, I just had to do one more - the brilliant - ZDoggMD (AKA Zubin Damania), who really is my brother from another mother.

Zubin is internal medicine physician in California (forgive him), although I must admit, I don't know what the heck internal medicine is, or how it differs from external medicine, and why they just can't call it "Medicine". He has been writing parody songs since his school days. He went to UCSF medical school, and further honed his fine sense of comedy whilst studying. He completed an internal medicine residency at Stanford, where he is now a full time hospitalist. In his spare time (!!) he writes, performs, produces and edits his award winning video blog at ZDoggMD.com (Medgadget Best New Weblog of 2010). 

His primary aim is to use humour to promote medical education, awareness, and also burnout prophylaxis for both patients as well as medical practitioners alike. 

“My hope is to make people laugh, and in the process make them aware of important issues impacting their health. If I get to beatbox with my homies while doing it, then that’s just cream, baby!”

Zubin, if you're reading this - much love to you. Peace.

Favourite Post: Doctor's Today - A Parody of Tonight Tonight 

A question for ZDogg - why does it still burn? ;)

ZDoggMD - Zubin Damania 

That concludes our look at our favourite blogs from 2011

0 - ZDoggMD - Zubin Damania

1 - EMCrit - Scott Weingart

2 - Life In The Fast Lane - Mike Cadogan, Chris Nickson & Co

3 - Academic Life in EM - Michelle Lin

4 - SMART EM - David Newman & Ashley Shreves

5 - ERCast - Rob Orman

6 - RESUS.ME - Cliff Reid

Happy new year everybody! 

The wind of change may bring some new blood to the site, as well as a potential podcast. Stay tuned....

Number 1 - EMCrit - Scott Weingart

Scott Weingart is currently an ED attending in the department of emergency at the Elmhurst Hospital Center, and an associate professor and the director of ED critical care at the Mount Sinai School of Medicine. He completed a residency in emergency medicine at Mount Sinai and subsequently completed fellowships in trauma and surgical critical care at the Shock Trauma Center in Baltimore.

Scott is a master communicator and educator, posting on and pushing the boundaries on topical themes related to ED critical care on his EMCrit podcast which receives well over 100,000 downloads per month, which incidentally also won Medgadget’s Best Medical Weblog of 2010 award.  In addition to the podcast, and blog, he also has a deep dive section on his site, looking at severe sepsis, and hypothermia, 2 topics that are a must read for any serious resuscitationist.  

As a self described ED Intesivist, his aim is to bring “upstairs care downstairs”, in other words, ICU level care to the critically ill patient in ED. You can also find Scott as a regular presenter on EM:RAP, as well as presenting at various emergency medicine & critical care conferences. I had the pleasure of meeting Scott at Essentials 2011 having followed the podcast and blog for some time, and not only is he a super talented educator, but also an all round nice guy. 

Favourite Post : EMCrit Podcast 18 - Infamous Awake Intubation Video where 2 of Scotts resident specialists volunteered to intubate each other awake!. A must see video! (These are trained professionals, don't try this at home!)

EMCrit Podcast, Scott Weingart

Aggressive fresh frozen plasma (FFP) with massive blood transfusion in the absence of acute traumatic coagulopathy

The level of evidence for high dose FFP in the setting of massive transfusion is low, and based primarily on retrospective & observational studies. These studies do not take into account the adverse effects of high dose FFP which include ARDS, circulatory overload, and possibly hypocalcaemia. In this paper, Mitra et al showed that in the absence of acute traumatic coagulopathy, high ratio FFP was not associated with a mortality benefit in the setting of Massive transfusion.

We do have to keep in mind that this is a retrospective look at data, although, conducting a randomised controlled trial that would be sufficiently powered would be very difficult.

INTRODUCTION:

A high ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBC) is currently recognised as the standard of care in some centres during massive transfusion post trauma. The aim of this study was to test whether the presumption of benefit held true for severely injured patients who received a massive transfusion, but did not present with acute traumatic coagulopathy.

PATIENTS AND METHODS:

Data collected in The Alfred Trauma Registry over a 6 year period were reviewed. Included patients were sub-grouped by a high FFP:PRBC ratio (≥1:2) in the first 4h and compared to patients receiving a lower ratio. Outcomes studied were associations with mortality, hours in the intensive care unit and hours of mechanical ventilation.

RESULTS:

Of 4164 eligible patients, 374 received a massive transfusion and 179 (49.7%) patients who did not have coagulopathy were included for analysis. There were 66 patients who received a high ratio of FFP:PRBC, and were similar in demographics and presentation to 113 patients who received a lower ratio. There was no significant difference in mortality between the two groups (p=0.80), and the FFP:PRBC ratio was not significantly associated with mortality, ICU length of stay or mechanically ventilated hours.

CONCLUSIONS:

A small proportion of major trauma patients received a massive blood transfusion in the absence of acute traumatic coagulopathy. Aggressive FFP transfusion in this group of patients was not associated with significantly improved outcomes. FFP transfusion carries inherent risks with substantial costs and the population most likely to benefit from a high FFP:PRBC ratio needs to be clearly defined. 

Injury. 2011 Nov 7. [Epub ahead of print]

IO Vs IV Access During Out of Hospital Cardiac Arrest, an RCT

EDTCC has no financial interests to declare in Vidacare Corp (although we wish we did ;))

So the Annals this month has a simple RCT, pitting traditional IV access against intraosseous access by tibial or humeral route. And guess what....intraosseous (tibial) emerged the clear winner in terms of first time success, and time to access...

Study objective

Intraosseous needle insertion during out-of-hospital cardiac arrest is rapidly replacing peripheral intravenous routes in the out-of-hospital setting. However, there are few data directly comparing the effectiveness of intraosseous needle insertions with peripheral intravenous insertions during out-of-hospital cardiac arrest. The objective of this study is to determine whether there is a difference in the frequency of first-attempt success between humeral intraosseous, tibial intraosseous, and peripheral intravenous insertions during out-of-hospital cardiac arrest.

Methods

This was a randomized trial of adult patients experiencing a nontraumatic out-of-hospital cardiac arrest in which resuscitation efforts were initiated. Patients were randomized to one of 3 routes of vascular access: tibial intraosseous, humeral intraosseous, or peripheral intravenous. Paramedics received intensive training and exposure to all 3 methods before study initiation. The primary outcome was first-attempt success, defined as secure needle position in the marrow cavity or a peripheral vein, with normal fluid flow. Needle dislodgement during resuscitation was coded as a failure to maintain vascular access.

Results

There were 182 patients enrolled, with 64 (35%) assigned to tibial intraosseous, 51 (28%) humeral intraosseous, and 67 (37%) peripheral intravenous access. Demographic characteristics were similar among patients in the 3 study arms. There were 130 (71%) patients who experienced initial vascular access success, with 17 (9%) needles becoming dislodged, for an overall frequency of first-attempt success of 113 (62%). Individuals randomized to tibial intraosseous access were more likely to experience a successful first attempt at vascular access (91%; 95% confidence interval [CI] 83% to 98%) compared with either humeral intraosseous access (51%; 95% CI 37% to 65%) or peripheral intravenous access (43%; 95% CI 31% to 55%) groups. Time to initial success was significantly shorter for individuals assigned to the tibial intraosseous access group (4.6 minutes; interquartile range 3.6 to 6.2 minutes) compared with those assigned to the humeral intraosseous access group (7.0 minutes; interquartile range 3.9 to 10.0 minutes), and neither time was significantly different from that of the peripheral intravenous access group (5.8 minutes; interquartile range 4.1 to 8.0 minutes).

Conclusion

Tibial intraosseous access was found to have the highest first-attempt success for vascular access and the most rapid time to vascular access during out-of-hospital cardiac arrest compared with peripheral intravenous and humeral intraosseous access.

Ann Emerg Med. 2011 Dec;58(6):509-16.