Intraosseous versus intravenous vascular access during cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a systematic review and meta-analysis of observational studies

Abstract

Introduction This study is aimed to investigate the association of intraosseous (IO) versus intravenous (IV) route during cardiopulmonary resuscitation (CPR) with outcomes after out-of-hospital cardiac arrest (OHCA). Methods We systematically searched PubMed, Embase, Cochrane Library and Web of Science from the database inception through April 2020. Our search strings included designed keywords for two concepts, i.e. vascular access and cardiac arrest. There were no limitations implemented in the search strategy. We selected studies comparing IO versus IV access in neurological or survival outcomes after OHCA. Favourable neurological outcome at hospital discharge was pre-specified as the primary outcome. We pooled the effect estimates in random-effects models and quantified the heterogeneity by the I2 statistics. Time to intervention, defined as time interval from call for emergency medical services to establishing vascular access or administering medications, was hypothesized to be a potential outcome moderator and examined in subgroup analysis with meta-regression. Results Nine retrospective observational studies involving 111,746 adult OHCA patients were included. Most studies were rated as high quality according to Newcastle-Ottawa Scale. The pooled results demonstrated no significant association between types of vascular access and the primary outcome (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.27–1.33; I2, 95%). In subgroup analysis, time to intervention was noted to be positively associated with the pooled OR of achieving the primary outcome (OR: 3.95, 95% CI, 1.42–11.02, p: 0.02). That is, when the studies not accounting for the variable of “time to intervention” in the statistical analysis were pooled together, the meta-analytic results between IO access and favourable outcomes would be biased toward inverse association. No obvious publication bias was detected by the funnel plot. Conclusions The meta-analysis revealed no significant association between types of vascular access and neurological outcomes at hospital discharge among OHCA patients. Time to intervention was identified to be an important outcome moderator in this meta-analysis of observation studies. These results call for the need for future clinical trials to investigate the unbiased effect of IO use on OHCA CPR.

Route of drug administration in out-of-hospital cardiac arrest: A protocol for a randomised controlled trial (PARAMEDIC-3)

“… 6 To date, studies comparing the clinical-effectiveness of the IO and intravenous (IV) drug routes are limited to observational research. 6 , 7 , 8 These studies consistently show that the IO route, is associated with similar or worse outcomes. However, the findings of these observational studies are challenging to interpret in the context of important residual confounding and resuscitation time bias.…”

Impact of the route of adrenaline administration in patients suffering from out-of-hospital cardiac arrest on 30-day survival with good neurological outcome (ETIVIO study)

“…Retrospective studies in humans demonstrated a time advantage of IO vs. IV access [ 22 , 23 ], while non-inferiority studies failed to find a significant disadvantage of IO access for clinical outcomes [ 24 ]. A current systematic review [ 25 ], investigating the effects of venous access type on neurological outcome and survival in OHCA, reported no difference between IV and IO access in the pooled analysis of nine observational studies after correcting for time between cardiac arrest and drug administration. Another systematic review [ 26 ], comparing IV and IO routes during cardiac arrest, found limited evidence in favor of IV administration in observational studies and no effect in the subgroup analyses of the randomized controlled trials reviewed.…”

Association of intraosseous and intravenous access with patient outcome in out-of-hospital cardiac arrest

“…There is only limited knowledge on the effect of administration site and the outcomes “survival” or “favourable neurological outcome”. Reports from several clinical studies vary with findings of both similar outcomes regardless of access route 39 – 41 and differing outcomes 16 – 19 , 42 , 43 when comparing intraosseous drug delivery and intravenous drug delivery in OHCA patients.…”