Intravenous vs. Intraosseous Vascular Access During Out-of-Hospital Cardiac Arrest - IVIO

Nov 06, 2024
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Author/Summarized by Author:
Amit Saha, MD
Summary Reviewer:
Anthony A. Bavry, MD,MPH,FACC
Trial Sponsor:
Novo Nordisk Foundation
Date Published:
10/31/2024
Date Updated:
11/06/2024
Original Posted Date:
11/06/2024
References

Contribution To Literature:

The IVIO trial showed that in patients with nontraumatic out-of-hospital cardiac arrest requiring drug administration, an intraosseous-first vascular access strategy did not increase likelihood of sustained ROSC or 30-day survival compared with an IV-first strategy.

Description:

The goal of the trial was to compare the efficacy and safety of an initial vascular access strategy of intraosseous (IO) versus peripheral intravenous (IV) access for medication administration in nontraumatic out-of-hospital cardiac arrest.

Study Design

  • Multicenter (Denmark)
  • Open-label
  • Randomized

Patients with out-of-hospital cardiac arrest were randomized in a 1:1 fashion in the field by an on-site clinician to initial IO (n = 731) or peripheral IV access (n = 748). The IO arm was further randomized 1:1 to humeral (n = 361) or tibial access (n = 370). In either group, vascular access strategy after two failed attempts was at the discretion of the paramedic team. Informed consent for enrollment was obtained following resuscitation from the patient or their legal representative.

  • Total number of enrollees: 1,479
  • Duration of follow-up: 1 year
  • Mean patient age: 69 years
  • Percentage female: 30%

Inclusion criteria:

  • Age ≥18 years
  • Out-of-hospital cardiac arrest undergoing cardiopulmonary resuscitation (CPR)
  • Need for vascular access to administer cardiac arrest medications

Exclusion criteria:

  • Known or suspected traumatic etiology of cardiac arrest
  • Established vascular access

Other salient features/characteristics:

  • Initial shockable rhythm: 23%
  • Witnessed cardiac arrest: 43%
  • Bystander CPR performed: 80%
  • Shock administered by bystander: 11%

Principal Findings:

The primary outcome, sustained return of spontaneous circulation (ROSC), for IO vs. IV, was: 30% vs. 29%, relative risk (RR) 1.06 (95% confidence interval [CI] 0.90-1.24), p = 0.49.

Secondary outcomes for IO vs. IV:

  • 30-day survival: 12% vs. 10%, RR 1.16 (95% CI 0.87-1.56)
  • 90-day survival: 11% vs. 10%, RR 1.18 (95% CI 0.88-1.60)
  • 30-day modified Rankin scale (mRS) score ≤3 among survivors: 9% vs. 8%, RR 1.16 (95% CI 0.83-1.62)
  • 90-day mRS score ≤3 among survivors: 10% vs. 9%, RR 1.20 (95% CI 0.88-1.65)

Vascular access characteristics for IO vs. IV:

  • Median time from emergency call to vascular access: 14 vs. 14 minutes
  • Median time from emergency call to epinephrine administration: 15 vs. 15 minutes
  • First successful vascular access according to assigned treatment strategy: 90% vs. 72%

Outcomes of humeral vs. tibial IO access:

  • Successful vascular access within two attempts: 90% vs. 93%
  • Sustained ROSC: 30% vs. 31%, RR 0.98 (95% CI 0.79-1.22)
  • Correct catheter positioning in patients undergoing computed tomography imaging: 71% (of 32) vs. 100% (of 35) 

Interpretation:

The IVIO trial demonstrated no increase in ROSC with a primary IO vs. IV access strategy in out-of-hospital cardiac arrest. Within the IO arm, the primary endpoint similarly did not differ between humeral and tibial access strategies, although the former demonstrated higher rates of catheter malposition in a nonrandomized subset. This intentional design to compare IO access strategies contrasts with prior data and, though an exploratory outcome, lends new evidence against an anatomic approach in IO access having a significant impact on the success of resuscitative efforts.

Thirty-day survival was double that observed in the simultaneously published PARAMEDIC-3 trial and comparable to the preceding VICTOR study in Taiwan. This may be due to similar patterns in time to epinephrine administration, which was comparatively delayed in PARAMEDIC-3. The combined data from these three trials in separate populations do not provide evidence to support an IO-first approach to vascular access in out-of-hospital cardiac arrest. The observed differences in IO catheter positioning and dislodgment by anatomic site are hypothesis-generating and may guide further study into best practices for IO access when performed in cardiac arrest.

References:

Vallentin MF, Granfeldt A, Klitgaard TL, et al. Intraosseous or Intravenous Vascular Access for Out-of-Hospital Cardiac Arrest. N Engl J Med 2024;Oct 31:[Epub ahead of print].

Nielsen N. Editorial: The Way to a Patient’s Heart — Vascular Access in Cardiac Arrest. N Engl J Med 2024;Oct 31:[Epub ahead of print].

Clinical Topics: Arrhythmias and Clinical EP, SCD/Ventricular Arrhythmias, Cardiovascular Care Team, Vascular Medicine

Keywords: Out-of-Hospital Cardiac Arrest, Return of Spontaneous Circulation, Vascular Access Devices


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