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Three Part Question

In [children presenting to the emergency department with paroxysmal supraventricular tachycardia] is [administration of intraosseous adenosine effective] in [terminating the rhythm disturbance?]

Clinical Scenario

A one-year-old girl presents to your Emergency Department with palpitations. The ECG recording is consistent with supraventricular tachycardia. You attempt to gain venous access multiple times but are unsuccessful. You wonder if the intraosseous delivery of adenosine is as effective as the intravenous one in terminating the arrhythmia

Search Strategy

Medline 1946 to Week 1 March 2014 using the OVID interface. Search limited to paediatric population, English language and human studies.
[(exp Adenosine/) OR (adenosine.mp)] AND [(exp Infusions, Intraosseous/) OR (intraosseous.mp) OR (IO.mp)] AND [(exp Tachycardia, Supraventricular/) OR (supraventricular tachycardia.mp) OR (SVT.mp)]

EMBASE. Same limits as per previous search.
[(exp adenosine/) AND (exp intraosseous drug administration/) AND (exp supraventricular tachycardia/)]

Cochrane database of Systematic Reviews using the terms adenosine and intraosseous

Search Outcome

The Medline search strategy revealed five articles. Following abstract review, two were found to be relevant to the question.
The EMBASE search revealed one article, not relevant to the clinical query.
The Cochrane database search yielded no relevant review.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Friedman FD, 1996, USA	11 day old female, with previous SVT refractory to adenosine.	Case report	Cardioversion to sinus rhythm	SVT terminated at 100µg/kg on both occasions	Patient on propranolol to maintain NSR after previous SVTs. An early dose was given prior to attempted cardioversion Saline flush volume not reported
Goodman I, 2012, USA	2-month year old male. 4-month year old male.	Case series report	Cardioversion to sinus rhythm	Case 1. IO 250 µg/kg used was unsuccessful. 100µg/kg delivered via a peripheral vein was successful. Case 2. IO 200µg/kg was unsuccessful. IV procainamide and then amiodarone successfully terminated the SVT	Case 2 patient was administered propranolol before attempted adenosine cardioversion Saline flush volume not reported.

Comment(s)

The intraosseous method allows rapid access to a venous system within the bone marrow and is uncollapsable unlike the peripheral veins. In the included cases, intraosseous access was gained through the proximal tibia. It is unclear why the intraosseous bolus of adenosine failed in Goodman’s patients, but was successful in Freidman’s but may be related to speed of administration and the volume of saline used in flushing the adenosine through. In the published cases, there were no adverse effects reported secondary from the administered adenosine.

Clinical Bottom Line

There is weak and contradicting evidence to suggest that SVTs can be terminated by intraosseous delivery of adenosine in selected cases. It is however unlikely to be as effective as the central or peripheral routes of administrations. Further well-constructed studies with large cohorts of patients are however needed to answer this question.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Friedman FD. Intraosseous adenosine for the termination of supraventricular tachycardia in an infant Annals of Emergency Medicine. 1996; 28:356-8.
2. Goodman I, Lu CJ. Intraosseous infusion is unreliable for adenosine delivery in the treatment of supraventricular tachycardia. Pediatric emergency care. 2012;28;47-8.