Dumas RP, Vella MA, Maiga AW, et al. Moving the needle on time to resuscitation: An east prospective Multicenter Study of vascular access in hypotensive injured patients using Trauma Video Review. Journal of Trauma and Acute Care Surgery. 2023;Publish Ahead of Print. doi:10.1097/ta.0000000000003958
Moving the Needle on Time to Resuscitation:
An EAST Prospective Multicenter Study of Vascular Access in Hypotensive Injured Patients Using Trauma Video Review
Objective
- Assess which access strategy, intraosseous (IO) vs. peripheral IV (PIV) vs. central venous catheter (CVC), would achieve faster and more successful vascular access placement in hypotensive trauma patients by using trauma video review (TVR) technology.
In hypotensive trauma patients with hemorrhagic shock, rapid vascular access is critical to ensure timely transfusions and administration of therapies to control blood loss and save lives. However, vascular access remains a significant challenge in this patient population due to vascular collapse and increased vascular tone. Little is known about how long it takes to establish vascular access in these patients and what is the most successful access route.
The purpose of this study was to evaluate which access strategy, intraosseous (IO) vs. peripheral IV (PIV) vs. central venous catheter (CVC), would achieve faster and more successful vascular access in hypotensive trauma patients by using trauma video review (TVR) technology.
An Eastern Association for the Surgery of Trauma (EAST) prospective, multicenter trial was performed across 19 centers in the U.S. between May 2021 and May 2022. The study cohort consisted of adult (≥16 years) trauma patients with systolic blood pressure (SBP) <90mmHg, who had vascular access placed (IO, PIV, CVC) in the emergency department; excluded were those arriving with prehospital vascular access that did not require any additional access. The authors used TVR to evaluate the resuscitation procedures; used abstractions of audiovisual recordings to gather data about the type of vascular access, location, procedural durations, success rates on first attempt and subsequent attempts, and time to resuscitation; and results were compared among different access types (IO vs. PIV vs. CVC). Patient demographics and injury-related data were obtained from medical records. The primary outcomes of this study were success of the access attempt (defined as visualization of blood in IV tubing or successful flushing of catheter) and duration of each successful and failed attempt (defined as the interval between needle insertion and successful placement or stop time for failed attempts).
The secondary outcome was time to initiation of resuscitation (defined as the time to administration of intravenous fluid or blood).
The study cohort comprised 581 trauma patients (median age 40 [Interquartile range/IQR 27-59] years); 74.6% were male, and 45.9% were Caucasian. The most common type of injury was gunshot wound (34.9%), followed by motor vehicle crash (25.4%); the median Injury Severity Score was 22 [IQR 10-34], and the overall mortality was 44.7%. A total of 1,410 vascular access attempts were extracted. Of those, 1,397 were analyzed, and 13 (<1%) were excluded due to missing data. The majority of access attempts (932, 66.9%) were PIV, 204 (14.6%) attempts were IO, and 249 (17.9%) attempts were CVC.
Characteristics of patients in the study.
Abbreviations: IQR = Interquartile range; SBP = Systolic Blood Pressure; GCS = Glasgow Coma
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Success rates by IV access type attempt and position for all patients in the study.* = statistically significant (P= 0.001) between IO, CVC, or PIV, Fisher’s exact test.
Success rates were not different between sites by access type (P = 0.54 for tibia vs. humeral IO, P = 0.47 for femoral vs. subclavian vs. internal jugular CVC).
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The median number of access attempts per patient was 2 (IQR 1–3). Overall, 971/1,397 (69.5%) of the access attempts were successful. IO had a higher success rate on first attempt than PIV and CVC (189/204 [92.6%] vs. 625/932 [67.1%] vs. 147/249 [59.0%]; P<0.001) and remained higher for subsequent attempts (second attempt 85% vs. 59% vs. 69%; P=0.08; third attempt 100% vs. 33% vs. 67%; P=0.002). Access was less likely to be successful in females (64% vs. 71%; P=0.01) due to a difference in success rates in PIV (70% in males vs. 60% in females; P=0.002) that was not observed in IO or CVC.
In a univariate logistic regression analysis examining the influence of confounding patient and provider characteristics on the outcome of access success, the following factors were found to be associated with success (P≤0.2): female sex (OR 0.71, 95% CI 0.54–0.95), initial Glasgow Coma Scale (GCS) (OR 1.02, 95% CI 0.99–1.05), initial SBP (OR 1.00, 95% CI 0.99-1.01), and access type (OR 6.19, 95% CI 3.53–10.83 for IO and OR 0.71,
95% CI 0.52-0.97 for CVC referent to PIV). After controlling for sex, initial SBP, and GCS in a multivariate regression model, access type remained strongly associated with success (OR 7.87, 95% CI 4.20-14.70 for IO and OR 0.72, 95% CI 0.51–0.99 for CVC referent to PIV).
The median time from patient arrival to successful vascular access placement was 5.0 [IQR 3.2-8.0] minutes. Duration of access attempt was similar between IO (36 [IQR 23-60] seconds) and PIV (44 [IQR 31-61] seconds), but both were significantly faster (P<0.001 for both) vs. CVC (171 [IQR 105-298] seconds). There was no difference between the duration of successful and unsuccessful attempts for PIV (median 42 seconds vs. 48 seconds; P=0.10) and IO (median 36.5 seconds vs. 29 seconds; P=0.18), but successful attempts were significantly longer than failed attempts for CVC (median 177 seconds vs. 134.5 seconds;
P=0.003). Time to resuscitation initiation was significantly reduced in patients whose initial access attempt was IO (5.8 minutes vs. 6.7 minutes; P=0.015).
In a subset analysis of 129 (22.3%) patients arriving without prehospital vascular access, there were 430 vascular access attempts, of which 68.8% (296/430) were successful. IO had the highest success rate (90.6%) vs. PIV (65.1%) vs. CVC (56.0%), P<0.001. The median time to successful vascular access was 3.6 [IQR 2.68-6.03] minutes. When IO was used as the initial access attempt, time to resuscitation initiation was shorter by 1.8 minutes compared to PIV (5.7 minutes vs. 7.5 minutes; P=0.001).
Time to initation of resuscitation by vascular access type, stratified by the presence or absence of vascular access obtained in the prehospital setting.
Abbreviations: IO = Intraosseous; PIV = Peripheral IV; CVC = Central Venous Catheter; * = Statistically significant difference by Kruskal-Wallis test, P<0.001
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The study has several limitations. While IO access is more consistent, having a limited number of access sites, the location for peripheral and central venous devices is more variable and affected by clinician and patient factors. This may have led to an underestimation of the study effect size, with the difference between IO and other access strategies being even more pronounced. While time to vascular access was faster for IO, the difference in time to access between devices may not be clinically meaningful for all patients. The authors did not consider preparation time in measuring times for access attempts, which would have exacerbated the differences between devices, as IOs generally require less preparation time than PIVs, and both need less than CVCs. Despite substantial training, time point interpretation may have varied between centers and individuals. Lastly, after capturing successful device placement, the authors did not record whether the device remained functional or was used for the entire resuscitation.
The study concludes that IO was as quick as PIV in obtaining vascular access but had a superior success rate than PIV and CVC. When used as the initial vascular access strategy, IO was significantly more effective in reducing time to resuscitation, especially in patients arriving without prehospital vascular access. These findings suggest that IO access should be considered as the first-line access strategy in hypotensive trauma patients where rapid and successful vascular access is critical to ensure more expeditious resuscitation and to reduce the odds of mortality.
Conclusions
The authors concluded that:
- In hypotensive trauma patients, IO access was as fast as PIV access, and both were significantly faster than CVC
- IO access was significantly more successful than PIV and CVC on initial and subsequent attempts. 93% of the IO
insertions were successful on the first attempt, vs. 67% for PIV and 59% for CVC - When IO access was used as the initial access strategy, it significantly shortened the time to resuscitation initiation, especially in patients arriving without established prehospital access
- IO should be considered as first-line therapy in hypotensive trauma patients
Tables and figures recreated from original article
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