Plasma catecholamine levels following tracheal and intravenous epinephrine administration in swine
Introduction
Several case reports and studies have shown that effective systemic levels of epinephrine are reached by tracheal (t) administration 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15. The American Heart Association (AHA) has approved this application route in its recommendations for CPR and other life-threatening conditions in cases where there are difficulties in starting a safe intravenous line in time [16]. Several different e.t. administration techniques have been described 7, 8, 9, 11, 13, 14, 15. However, diversity of the CPR models and administration methods make it difficult to compare the effectiveness of the various methods. Therefore, the optimal e.t. delivery technique is still unknown [17]. So far, the AHA recommends to give the drugs via a catheter whose tip is placed beyond the end of the tracheal tube [16]. However, in a pediatric porcine hypoxic-hypercarbic cardiopulmonary arrest model Jasani et al did not find a difference between different e.t. administration techniques [17]. We compared the efficacy of three e.t. administration techniques and the intravenous administration on epinephrine plasma levels in an adult non-arrest porcine model. We hypothesized that plasma levels of e.t. administered epinephrine would not be different between three standardized instillation techniques and would be equivalent to plasma epinephrine levels after intravenous injection.
Section snippets
Materials and methods
The study was approved by the Governmental Review Board for the care of animal subjects. Care and handling of animals were in accordance with national and institutional regulations. Male and female conditioned domestic pigs were randomised into four groups: group IV: administration of epinephrine via a peripheral vein, and three different e.t. groups: group Tube: injection of epinephrine into the upper end of a regular tracheal tube, group Catheter: injection of epinephrine in a suction tube
Results
There were no differences between groups concerning biometric data (Table 1). Twenty-nine animals could be included for data analysis. In group Catheter arterial blood samples for one animal could not be taken on time due to catheter occlusion, in group IV one animal received the wrong drug dose, and in one animal the intravenous injection infiltrated. Norepinephrine levels remained constant throughout with no differences between groups (Fig. 1). Within 0.5 min after dosing a significant
Discussion
In CPR situations, most patients are intubated to protect the airway, to provide controlled ventilation and to optimize oxygen delivery [16]. As an additional benefit intubation offers an alternative route for administering life-saving drugs. This route, which is often more easily secured than a vascular access, leads to an extremely large absorptive area—the bronchoalveolar region. Though venous administration is recommended in the AHA guidelines, it is sometimes difficult to install a safe
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European Resuscitation Council Guidelines for Resuscitation 2015. Section 7. Resuscitation and support of transition of babies at birth
2015, ResuscitationCitation Excerpt :If adrenaline is used, an initial dose 10 micrograms kg−1 (0.1 ml kg−1 of 1:10,000 adrenaline) should be administered intravenously as soon as possible1,2,4 with subsequent intravenous doses of 10–30 micrograms kg−1 (0.1–0.3 ml kg−1 of 1:10,000 adrenaline) if required. The tracheal route is not recommended but if it is used, it is highly likely that doses of 50–100 micrograms kg−1 will be required.3,7,136,261–265 Neither the safety nor the efficacy of these higher tracheal doses has been studied.
European Resuscitation Council Guidelines for Resuscitation 2010. Section 7. Resuscitation of babies at birth
2010, ResuscitationCitation Excerpt :This is consistent with evidence extrapolated from neonatal animal models indicating that higher doses (50–100 μg kg−1) of adrenaline may be required when given via the tracheal route to achieve the same blood adrenaline concentrations and haemodynamic response as achieved after intravenous administration.88,89 Adult animal models demonstrate that blood concentrations of adrenaline are significantly lower following tracheal compared with intravenous administration90,91 and that tracheal doses ranging from 50 to 100 μg kg−1 may be required to achieve ROSC.92 Although it has been widely assumed that adrenaline can be given faster by the tracheal route than by the intravenous route, no clinical trials have evaluated this hypothesis.
Part 11: Neonatal resuscitation: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations
2010, ResuscitationCitation Excerpt :This is consistent with evidence extrapolated from neonatal animal models indicating that higher doses (0.05–0.1 mg kg−1) of tracheal adrenaline may be required to achieve increased blood adrenaline concentrations and a haemodynamic response equivalent to intravenous administration (LOE 598,99). Evidence extrapolated from adult animal models indicates that blood concentrations of adrenaline are significantly lower following tracheal administration (LOE 5100,101), and tracheal doses ranging from 0.05 mg kg−1 to 0.1 mg kg−1 may be required to achieve ROSC (LOE 5102). Although it has been widely assumed that adrenaline can be administered faster by the tracheal route than by the intravenous route, no clinical trials have evaluated this hypothesis.
Endotracheal delivery of medications during neonatal resuscitation
2006, Clinics in Perinatology