Intraosseous versus intravenous vascular access in upper extremity among adults with out-of-hospital cardiac arrest: cluster randomised clinical trial (VICTOR trial)

Abstract

Objective: To compare the effectiveness of intraosseous versus intravenous vascular access in the treatment of adult patients with out-of-hospital cardiac arrest.

Design: Cluster randomised controlled trial.

Setting: The VICTOR (Venous Injection Compared To intraOsseous injection during resuscitation of patients with out-of-hospital cardiac arrest) trial involved emergency medical service agencies with all four advanced life support ambulance teams in Taipei City, Taiwan. The enrolment period spanned 6 July 2020 to 30 June 2023 and was temporarily suspended between 20 May 2021 and 31 July 2021 owing to the covid-19 pandemic.

Participants: Adult (age 20-80 years) patients with non-traumatic out-of-hospital cardiac arrest.

Interventions: Biweekly randomised clusters of four participating advanced life support ambulance teams were assigned to insert either intravenous or intraosseous access.

Main outcome measures: The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation, sustained return of spontaneous circulation (≥2 hours), and survival with favourable neurological outcomes (cerebral performance category score ≤2) at hospital discharge.

Results: Among 1771 enrolled patients, 1732 (741 in the intraosseous group and 991 in the intravenous group) were included in the primary analysis (median age 65.0 years; 1234 (71.2%) men). In the intraosseous group, 79 (10.7%) patients were discharged alive, compared with 102 (10.3%) patients in the intravenous group (odds ratio 1.04, 95% confidence interval 0.76 to 1.42; P=0.81). The odds ratio of intraosseous versus intravenous access was 1.23 (0.89 to 1.69; P=0.21) for pre-hospital return of spontaneous circulation, 0.92 (0.75 to 1.13; P=0.44) for sustained return of spontaneous circulation, and 1.17 (0.82 to 1.66; P=0.39) for survival with favourable neurological outcomes.

Conclusions: Among adults with non-traumatic out-of-hospital cardiac arrest, initial attempts to establish vascular access through the intraosseous route did not result in different outcomes compared with intravenous access in terms of the proportion of patients surviving to hospital discharge, pre-hospital return of spontaneous circulation, sustained return of spontaneous circulation, and favourable neurological outcomes.

Trial registration: NCT04135547ClinicalTrials.gov NCT04135547.

Fig 1

Flowchart of patients through trial. *Recruitment was temporarily suspended between 20 May 2021 and 31 July 2021 owing to covid-19 pandemic. †Other pre-defined exclusion criteria include traumatic cardiac arrest, known or suspected pregnancy, age <20 or >80 years, cancelled ambulance call, or patient being transported to hospital before arrival of emergency medical technician-paramedic (EMT-P)

Fig 2

Subgroup analyses of primary outcome. CPR=cardiopulmonary resuscitation; EMS=emergency medical service

Fig 3

Survival with favourable neurological outcomes at hospital discharge. Patients’ Cerebral Performance Category scores ranged from 1 (good cerebral performance) to 5 (brain death). Data are presented on log10 scale as percentage of patients in each group. IO=intraosseous; IV=intravenous