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

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Abstract
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; I 2 = 84%), sustained return of spontaneous circulation (RR = 0.87, 95% CI: [0.77–0.97]; P = .02; I 2 = 53%) and favorable neurological outcomes at hospital discharge (RR = 0.58, 95% CI: [0.45–0.73]; P < .00001; I 2 = 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; I 2 = 49%) and at hospital discharge (RR = 0.59; 95% CI: [0.45–0.78]; P < .0002; I 2 = 95%) and short-term survival (RR = 0.52; 95% CI: [0.32–0.86]; P = .010; I 2 = 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.

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