Out-of-Hospital Cardiac Arrest

IJCS

Editorial

The Route to Survival: Intravenous or Intraosseous Access in Cardiac Arrest

Imara Correia de Queiroz Barbosa et al. Larissa Neto Espíndola Ana Claudia Andrade Lucena Fátima Elizabeth Fonseca De Oliveira Negri Catia Sueli de Sousa Eufrazino Gondim

Out-of-hospital cardiac arrest (OHCA) continues to be one of the major challenges in emergency cardiovascular care. Despite advances in cardiopulmonary resuscitation (CPR) and defibrillation, overall survival rates remain low worldwide. Current international guidelines recommend the establishment of intravenous (IV) access as the first-line route for drug administration, while intraosseous (IO) access is suggested as an alternative when IV access cannot be promptly achieved.^1,2 In this context, every minute counts, and establishing vascular access for drug delivery is often a race against time. However, a long-standing question still persists: does the route of administration – intravenous or intraosseous – truly impact outcomes?

In this issue of the International Journal of Cardiovascular Sciences, Cavalcante et al. present a comprehensive meta-analysis comparing IO and IV access in adults with OHCA. Pooling data from more than 9,000 patients across three major randomized clinical trials,^3-5 the authors demonstrate that both routes yield similar results in terms of survival, with favorable neurological outcomes, the return of spontaneous circulation (ROSC), and survival to hospital discharge.⁶ Moderate heterogeneity was limited to the ROSC outcome, likely due to differences in its definition among studies. Beyond this, the evidence is consistent in showing that time to drug delivery, rather than the route of administration, determines patient outcomes.⁶

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IJCS

Original Article

Intraosseous Versus Intravenous Vascular Access for Out-Of-Hospital Cardiac Arrest: A Meta-Analysis of Randomized Clinical Trials

Milene Vitória Sampaio Sobral et al. Rafaela da Cunha Pirolla Douglas Nunes Cavalcante Nicoly Franciely Sanches Leme … Paula Rocha Fernanda Segura Campos Leonardo Castro Luna

Abstract

Background:

Out-of-hospital cardiac arrest (OHCA) is a life-threatening emergency characterized by low survival rates. Vascular access is critical for drug administration during resuscitation. While intravenous (IV) access is the standard, intraosseous (IO) access may provide practical advantages in certain emergencies.

Objectives:

This meta-analysis aimed to compare IO versus IV access in adult OHCA patients regarding their impact on survival and neurological outcomes.

Methods:

A systematic search of MEDLINE, Embase, and Cochrane CENTRAL through November 2024 was conducted, including randomized controlled trials (RCTs) comparing IO and IV access in adult patients with OHCA. Meta-analyses employed a random-effects model. A p-value < 0.05 was considered statistically significant. Analyses outcomes included survival with a favorable neurological outcome, survival to hospital discharge, return of spontaneous circulation (ROSC), and sustained ROSC. Subgroup analyses were conducted based on initial rhythm and bystander-performed cardiopulmonary resuscitation. The certainty of the evidence was determined using the GRADE approach. Results: Three RCTs involving 9,119 patients were included. IO access showed no significant differences compared to IV access in terms of survival with favorable neurological outcome (OR 1.07; 95% CI 0.88–1.30; p = 0.49; I² = 0%), survival to hospital discharge (OR 0.97; 95% CI 0.80–1.19; p = 0.80; I² = 0%), ROSC (OR 1.00; 95% CI 0.83–1.22; p = 0.97; I² = 64%), or sustained ROSC (OR 0.92; 95% CI 0.80–1.06; p = 0.25; I² = 44%).

Conclusions:

IO and IV access yield comparable outcomes in OHCA patients, supporting their use based on clinical context and provider expertise. Further research is needed to confirm these findings across diverse healthcare settings.