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Meta-Analysis
. 2025 Feb:207:110481.
doi: 10.1016/j.resuscitation.2024.110481. Epub 2024 Dec 30.

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

Keith Couper  1 , Lars W Andersen  2 , Ian R Drennan  3 , Brian E Grunau  4 , Peter J Kudenchuk  5 , Ranjit Lall  6 , Eric J Lavonas  7 , Gavin D Perkins  8 , Mikael Fink Vallentin  9 , Asger Granfeldt  10 ; International Liaison Committee on Resuscitation Advanced Life Support Task Force
Collaborators, Affiliations
Free article
Meta-Analysis

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

Keith Couper et al. Resuscitation. 2025 Feb.
Free article

Abstract

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 4th 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.

Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Epinephrine; Intraosseous; Intravenous; Systematic review.

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Conflict of interest statement

Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: KC, RL, and GDP are PARAMEDIC-3 trial investigators (Couper at al 2024).(27) LWA, MFV, and AG are IVIO trial investigators (Vallentin et al 2024).(23) GDP is an editor of Resuscitation. KC, LWA, IRD, PJK, and RL are editorial board members of Resuscitation.

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