Hooper Amy, Nolan Jerry P, Rees Nigel, Walker Alison, Perkins Gavin D, Couper Keith
Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK.
Resuscitation. 2022 Dec;181:70-78. doi: 10.1016/j.resuscitation.2022.10.015. Epub 2022 Oct 26.
Recent evidence showing the clinical effectiveness of drug therapy in cardiac arrest has led to renewed interest in the optimal route for drug administration in adult out-of-hospital cardiac arrest. Current resuscitation guidelines support use of the intravenous route for intra-arrest drug delivery, with the intraosseous route reserved for patients in whom intravenous access cannot be established. We sought to evaluate current evidence on drug route for administration of cardiac arrest drugs, with a specific focus on the intravenous and intraosseous route. We identified relevant animal, manikin, and human studies through targeted searches of MEDLINE in June 2022. Across pre-hospital systems, there is wide variation in use of the intraosseous route. Early administration of cardiac arrest drugs is associated with improved patient outcomes. Challenges in obtaining intravenous access mean that the intraosseous access may facilitate earlier drug administration. However, time from administration to the central circulation is unclear with pharmacokinetic data limited mainly to animal studies. Observational studies comparing the effect of intravenous and intraosseous drug administration on patient outcomes are challenging to interpret because of resuscitation time bias and other confounders. To date, no randomised controlled trial has directly compared the effect on patient outcomes of intraosseous compared with intravenous drug administration in cardiac arrest. The International Liaison Committee on Resuscitation has described the urgent need for randomised controlled trials comparing the intravenous and intraosseous route in adult out-of-hospital cardiac arrest. Ongoing clinical trials will directly address this knowledge gap.
近期证据表明药物治疗在心脏骤停中具有临床有效性，这引发了人们对成人院外心脏骤停时药物给药最佳途径的新兴趣。当前的复苏指南支持在心脏骤停期间通过静脉途径给药，而骨内途径则用于无法建立静脉通路的患者。我们试图评估关于心脏骤停药物给药途径的现有证据，特别关注静脉和骨内途径。我们通过2022年6月对MEDLINE进行定向检索，确定了相关的动物、人体模型和人体研究。在各个院前系统中，骨内途径的使用存在很大差异。早期给予心脏骤停药物与改善患者预后相关。获得静脉通路存在挑战，这意味着骨内通路可能有助于更早给药。然而，由于药代动力学数据主要限于动物研究，给药至中心循环的时间尚不清楚。由于复苏时间偏差和其他混杂因素，比较静脉和骨内给药对患者预后影响的观察性研究难以解释。迄今为止，尚无随机对照试验直接比较骨内给药与静脉给药对心脏骤停患者预后的影响。国际复苏联合委员会描述了迫切需要进行随机对照试验，以比较成人院外心脏骤停时静脉和骨内途径。正在进行的临床试验将直接填补这一知识空白。
