Comparing intraosseous versus intravenous access for resuscitation in out-of-hospital cardiac arrest: A systematic review and GRADE meta-analysis.

BACKGROUND

Out-of-hospital cardiac arrest, which poses a severe challenge due to high mortality rates in emergency cases, warrants the need for effective resuscitation measures. This meta-analysis evaluated survival outcomes for intraosseous (IO) versus intravenous (IV) drug administration.

METHODS

Electronic databases, including PubMed, Cochrane Central, and ScienceDirect, were searched from inception until September 2024. Risk ratios (RRs) and 95 % confidence intervals (CIs) were pooled using Review Manager version 5.4.1 under a random-effects model for dichotomous outcomes. The quality of the studies was evaluated using the Cochrane Risk of Bias tool (RoB 2.0) and Newcastle-Ottawa Scale. Certainty of evidence was assessed through the grading of recommendations, assessment, development, and evaluations assessment.

RESULTS

The quantitative analysis included 18 studies comprising a total sample size of 245,132 patients. IO route was associated with a significantly lower return of spontaneous circulation (RR = 0.77, 95% CI: [0.71-0.83]; P < .00001; I2 = 84%), sustained return of spontaneous circulation (RR = 0.87, 95% CI: [0.77-0.97]; P = .02; I2 = 53%) and favorable neurological outcomes at hospital discharge (RR = 0.58, 95% CI: [0.45-0.73]; P < .00001; I2 = 81%) compared to IV route. It also showed a significantly lower survival at hospital arrival (RR = 0.79; 95% CI: [0.72-0.86]; P < .00001; I2 = 49%) and at hospital discharge (RR = 0.59; 95% CI: [0.45-0.78]; P < .0002; I2 = 95%) and short-term survival (RR = 0.52; 95% CI: [0.32-0.86]; P = .010; I2 = 72%). No publication bias was detected.

CONCLUSION

This meta-analysis showed that IV access is superior to IO in terms of favorable neurological outcomes and survival to hospital arrival and discharge in out-of-hospital cardiac arrest patients. This suggests that when feasible, the IV route should be preferred in emergency resuscitation protocols.