Clinical trial NCT04135547: Venous Injection Compared To intraOsseous Injection During Resuscitation of Patients With Out-of-hospital Cardiac Arrest
Official title: Venous Injection Compared To intraOsseous Injection During Resuscitation of Patients With Out-of-hospital Cardiac Arrest (The VICTOR Trial)
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Emergency Medical Service
Out-of-Hospital Cardiac Arrest
Vascular Access
Intraosseous Access
Intravenous Access
Lead sponsor: National Taiwan University Hospital
Sponsor class: OTHER
Collaborators: name: Ministry of Science and Technology, Taiwan
name: Teleflex
First posted: 2019-10-22
Enrollment: 1732
Sex: ALL
Minimum age (years): 20
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Intervention model description: randomized clinical trial
Primary purpose: TREATMENT

Brief summary: Overall survival of patients after out-of-hospital cardiac arrest (\*OHCA\*) is less than 10% worldwide and in Taiwan. Interventions provided by the emergency medical system (\*EMS\*) before arrival at the hospital are of paramount importance to patient outcomes after OHCA. Among those interventions, the pros-and-cons of different vascular accesses, including intraosseous (\*IO\*) access or intravenous (\*IV\*) access, remained the issue of most under debate.

The objective of this study is to determine the comparative effectiveness of IO access vs IV access in patients with OHCA by a randomized controlled trial (\*RCT\*) in Taipei EMS. To name in short, the investigators called it a "\*VICTOR\* trial" standing for "Venous Injection Compared To intraOsseous injection during Resuscitation of patients with out-of-hospital cardiac arrest".

Detailed description: Overall survival of patients after out-of-hospital cardiac arrest (\*OHCA\*) is less than 10% worldwide and in Taiwan. Interventions provided by the emergency medical system (\*EMS\*) before hospital care is of paramount importance to patient outcomes after OHCA. Among those interventions, the pros and cons of different vascular accesses, including intraosseous (\*IO\*) access or intravenous (\*IV\*) access, recently became the focus under debate.

Theoretically, IO access provides a rapidly established way to administrate medication and fluid to patients (Reference 1) and has been adopted in many acute care societies and organizations including current resuscitation guidelines (Reference 2). However, some of the recent publications questioned the outcomes of OHCA patients receiving the IO route comparing to the IV route (References 3-5). Studies showed non-different or negative outcomes of patients receiving the IO route has been severely biased through the inherent inadequacy of retrospective design (References 3-5). The three major problems of those studies were:

1. . Time to vascular access cannot be adjusted. In many EMS, IO access was allowed only after one or two failed attempts of IV route. This led to a significant selection bias.
2. . The location of vascular access was not accurately reported. As we know, medications through upper limbs arrive at the heart sooner than the lower limbs. Many paramedics tend to insert the IO needle in tibia but to inset IV catheters in the forearm vein.
3. . Post-hoc analysis with old data over 5 to 10 years. Two of the three studies were the post-hoc analysis from the data of previous studies which was conducted from 2007 to 2010 when cardiopulmonary resuscitation quality and teamwork (i.e. important confounding factors to OHCA survival) were not that emphasized and recorded.

Hence, the investigators designed the study to determine the comparative effectiveness of IO access vs IV access in patients with OHCA by a randomized controlled trial (\*RCT\*) in Taipei EMS. In this 2-year research plan, we will conduct a prehospital RCT to address the following question: In adult patients with non-traumatic cause of OHCA resuscitated by emergency medical technician paramedic in the prehospital setting, will receiving IO access cause a better chance of survival to discharge, sustained recovery of spontaneous circulation, and other survival outcomes like neurologically favorable status, comparing to those who receiving IV access.

To name in short, the investigators called it a "\*VICTOR\* trial" standing for "Venous Injection Compared To intraOsseous injection during Resuscitation of patients with out-of-hospital cardiac arrest".

Eligibility criteria: Inclusion Criteria:

* Out-of-hospital cardiac arrest (OHCA) activated Taipei EMS ALS team (EMTP)
* Adult ≥ 20 years old

Exclusion Criteria:

* OHCA patients with signs of obvious death, e.g. rigor mortis
* Existing do-not-attempt-resuscitation order
* Patients with cardiac arrest en route to the hospital
* OHCA patients with successful vascular access before EMTP arrival
* OHCA patients with a canceled ambulance call or being transported to the hospital before EMTP arrival
* OHCA patients with known or suspected pregnancy
* OHCA patients with traumatic cause of cardiac arrest
* OHCA patients with known or suspected \< 20 years old, or \> 80 years old
* OHCA patients with contraindications to IO access or IV access

Primary outcomes:
measure: the rate of survival to hospital discharge
timeFrame: up to 1 month after the OHCA event
Secondary outcomes:
measure: the time and rate of return of spontaneous circulation (*ROSC*)
timeFrame: up to 1 week after the OHCA event
measure: survival to admission
timeFrame: up to 1 week after the OHCA event
measure: favorable neurologic survival staus
timeFrame: up to 1 month after the OHCA event
Other outcomes:
measure: subgroups analysis
timeFrame: through study completion, an average of half a year
Locations:
city: Taipei
country: Taiwan
facility: National Taiwan University Hospital
Study officials:
affiliation: Dept. of Emergency Medicine, NTUH
name: Wen-Chu Chiang, PhD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Petitpas F, Guenezan J, Vendeuvre T, Scepi M, Oriot D, Mimoz O. Use of intra-osseous access in adults: a systematic review. Crit Care. 2016 Apr 14;20:102. doi: 10.1186/s13054-016-1277-6.
citation: Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, Neumar RW, O'Neil BJ, Paxton JH, Silvers SM, White RD, Yannopoulos D, Donnino MW. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S444-64. doi: 10.1161/CIR.0000000000000261. No abstract available.
citation: Kawano T, Grunau B, Scheuermeyer FX, Gibo K, Fordyce CB, Lin S, Stenstrom R, Schlamp R, Jenneson S, Christenson J. Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Ann Emerg Med. 2018 May;71(5):588-596. doi: 10.1016/j.annemergmed.2017.11.015. Epub 2018 Jan 6.
citation: Feinstein BA, Stubbs BA, Rea T, Kudenchuk PJ. Intraosseous compared to intravenous drug resuscitation in out-of-hospital cardiac arrest. Resuscitation. 2017 Aug;117:91-96. doi: 10.1016/j.resuscitation.2017.06.014. Epub 2017 Jun 16.
citation: Mody P, Brown SP, Kudenchuk PJ, Chan PS, Khera R, Ayers C, Pandey A, Kern KB, de Lemos JA, Link MS, Idris AH. Intraosseous versus intravenous access in patients with out-of-hospital cardiac arrest: Insights from the resuscitation outcomes consortium continuous chest compression trial. Resuscitation. 2019 Jan;134:69-75. doi: 10.1016/j.resuscitation.2018.10.031. Epub 2018 Nov 1.