Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Endotracheal Drug Administration in Cardiac Arrest – comment

Vince of Living La Vida Vince wanted to comment on Endotracheal Drug Administration in Cardiac Arrest. Where he works his Mojo, there are firewalls that do not like him, do not like my blog, or both. He asked me to post this comment. In between, I have responded.

Well, as much as I hate to, you know I cannot resist the urge to ‘poke the gorilla with the stick’, so here goes.

At least this gorilla is not locked up behind a firewall. 🙂

I agree, that given the widespread use of alternative venous access(IO), the ET route of medication administration during resuscitation is most likely of little value [and as you point out potentially harmful-although I would worry just as much about washing the ‘Mr. Bubbles’ away, as making it 😉 ]

A good point that I had not considered to be much of a problem, since I have seen ET drugs given more than occasionally in the ICU.

However, you know my feelings on retrospective studies in general, and this one is particularly horrible! In addition to all the patient disparity between the treatment arms, the ET group was 1.5 times more likely to be in asystole at the onset than the IV group! Might this impact the results? Furthermore, since this was retrospective, the medics doing the treating were not randomizing which patients were going to get ET vs. IV. My guess is that this was most certainly NOT random at all. A myriad of factors such as length of downtime, ability to attain IV access, Single provider vs. double provider etc. etc. etc. may have determined which route a provider chose and would most certainly skew any data.

As much as I am critical of bad research, I do not think this study should be dismissed entirely.

The researchers do make it clear that there are limitations. They discuss these limitations. And the most important reason we should not ignore it is that there is nothing else that is anywhere near as good in looking at ET drug administration in real patients. The patients were not randomized, but they probably did self select for the dosing route that would apply outside of the study. With use of IO (IntraOsseous) needles being common place, we could set up a study that randomizes patients to the IO route or the ET route. This study could be interesting, but would interesting justify doing this study, instead of something that would really matter in EMS?

So I would say that this “study” should be ignored, at least for the purposes of “ruling-out” the potential benefits of ET administration. Poor research is poor research. Trying to make chicken soup out of this chicken-shit is, at best, Quixotic.

This is unfortunately the nature of the beast when it comes to quality research surrounding resuscitation- there is a dearth of good data. Half-truths, anecdotes, bad ideas, and untested theories abound.

The lack of good research should lead us to prohibit this treatment, not permit it.

This study is not of the quality that should be required to advocate for a treatment. The level of evidence needed to eliminate a treatment should be significantly less than the level of evidence needed to recommend a treatment. If there is evidence of harm, you go back to the drawing board and figure out what can be done about the apparent harm. You do not say, Well, it is the standard of care and we need to have much more rigorous evidence to stop using this apparently dangerous treatment, because it is the standard of care.

This is part of my point in Narcan Solves Riddle – Part IV, How did this happen? – Research and Narrative Fallacy I. The level of evidence needed to discourage a treatment should be much lower than the level of evidence needed to treat.

The same is true in looking at an individual patient. We need to be much more rigorous about the things that lead us to be aggressive in treatment, than the things that lead us to be conservative in treatment.

On point of porcine lab testing- it has a valuable place in establishing that for certain formulations, the ET route can provide adequate absorption to approach blood levels established by IV routes – Charlotte and her web notwithstanding. Does this necessarily mean better outcomes? Of course not. Until we get some IRBs with a full compliment of testes*, this is the closest we are ever going to get to scientifically rigorous data on the subject.** (* sarcasm ** not sarcasm)

Perhaps we need to study testes implantation on IRBs.

As far as advocating for treatments because trying to make pigs fly is the closest to real research that we have, I disagree. The pigs do not adequately represent the nursing home patients who appear to be disproportionately selected for this treatment. That is just one of the significant differences. When performing research on other animals, to determine the effect on human animals, some animals are more equal than others. Animal studies do provide evidence to advocate for human testing. They do not provide evidence to advocate for human treatment outside of the well controlled study.

You do make a great point about arbitrary endpoints like presence of a pulse upon arrival.

Thank you.

Consider the pot stirred. It’s been a while! 😉

Always good to think about these things in different ways. For me, the narrative part that does not make sense is this –

Removing ventilation and circulation, just to provide medication, is not good medicine. Especially when the medication is of uncertain benefit when administered by the ideal route.

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Comments

  1. This a fabulous post and may be one that needs to be followed up to see what goes on

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