Intraosseous and intravenous vascular access during adult cardiac arrest: a systematic review and meta-analysis.

Objective: To summarise evidence on the clinical effectiveness of initial vascular attempts via the intraosseous route compared to the intravenous route in adult cardiac arrest.

Methods: We searched MEDLINE and Embase (OVID platform), the Cochrane library, and the International Clinical Trials Registry Platform from inception to September 4^th 2024 for randomised clinical trials comparing the intraosseous route with the intravenous route in adult cardiac arrest. Our primary outcome was 30-day survival. Secondary outcomes included favourable neurological outcome at 30-days/ hospital discharge and return of spontaneous circulation (both any ROSC and sustained ROSC). We performed meta-analyses using a fixed-effect model. We assessed risk of bias using the Cochrane Risk of Bias-2 tool and evidence certainty using the GRADE approach.

Results: We included three randomised clinical trials encompassing 9,332 participants with out-of-hospital cardiac arrest. Initial attempts via the intraosseous, compared with intravenous, route did not increase the odds of 30-day survival (odds ratio 0.99, 95% confidence interval 0.84-1.17; 9,272 participants; three trials; moderate-certainty evidence) or favourable neurological outcome at 30-days/ hospital discharge (odds ratio 1.07, 95% confidence interval 0.88-1.30; 9,186 participants; three trials; low-certainty evidence). The odds of achieving sustained return of spontaneous circulation were lower in the intraosseous group (odds ratio 0.89, 95% confidence interval 0.80-0.99; 7,518 participants; two trials; moderate-certainty evidence).

Conclusion: Initial vascular access attempts via the intraosseous, compared with intravenous, route in adult cardiac arrest did not improve 30-day survival and may reduce the odds of a sustained return of spontaneous circulation.