Safety and Efficacy of Intra-Osseous versus Intravenous Vascular Access for Out-of-Hospital Cardiac Arrest - Systematic Review and Meta-Analysis

Sep 28, 2026

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Safety and efficacy of intraosseous (IO) versus intravenous (IV) vascular access in out-of-hospital cardiac arrest (OHCA) are evaluated through a systematic review and meta-analysis. Searches in PubMed, EMbase, Google Scholar, and the Cochrane Library identified studies published up to February 20, 2025. Twenty-three studies (48945 IO, 188966 IV) were included. Favorable neurological outcomes were similar (OR 0.73). IO access showed lower odds of shockable rhythms and, in pediatric OHCA, lower ROSC, with heterogeneity and bias warranting cautious interpretation.

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Background

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Results

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Therapeutics and Clinical Risk Management Open Access Full Text Article REVIEW Safety and Efficacy of Intra-Osseous versus Intravenous Vascular Access for Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis Mengjie Cai 1 , Yu Dai2 1Outpatient Service, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, 311101, People’s Republic of China; 2ICU, Jiangshan People’s Hospital, Quzhou, Zhejiang, 324199, People’s Republic of China Correspondence: Mengjie Cai, Outpatient Service, The First Affiliated Hospital of Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou, Zhejiang, 311101, People’s Republic of China, Email [18069889223@163.com](18069889223@163.com) | Background: The immediate administration of drugs and fluids is critical for successful resuscitation in out-of-hospital cardiac arrest (OHCA) . Vascular access selection plays a pivotal role in ensuring timely delivery of therapeutic interventions during OHCA management. This study aims to compare the safety and efficacy of intraosseous (IO) and intravenous (IV) access in OHCA management.
Methods: We conducted a comprehensive search of PubMed, EMbase, Google Scholar, and the Cochrane Library databases to identify studies published up to February 20th, 2025, evaluating IO and IV access in OHCA patients. The outcomes of interest included return of spontaneous circulation (ROSC), survival from hospital admission to discharge, neurological outcome, comorbidities, and access time.
Results: Twenty-three studies, comprising 48945 cases of IO access and 188966 cases of IV access for OHCA management, were included. Overall, the rate of favorable neurological outcome was similar between patients with IO and IV access (odds ratio [OR] = 0.73; 95% confidence interval [CI] = 0.37 to 1.45, I2=95 .3%) . IO access was associated with significantly lower odds of shockable rhythms in both adult (OR = 0.77; 95% CI = 0.70 to 0. 85, I2=86%) and pediatric (OR = 0.20; 95% CI = 0.12 to 0.33) patients. Additionally, IO access was linked to a lower rate of ROSC in pediatric OHCA patients (OR = 0.30; 95% CI = 0.21 to 0.42) . Prospective studies and those with unadjusted time to intervention analysis demonstrated markedly lower rates of survival at discharge, favorable neurological outcome, and ROSC in the IO group compared to the IV group. It should also be noted that the interpretation of the results should take into account the high heterogeneity and potential biases, despite the corresponding subgroup analyses we conducted.
Conclusion: In OHCA management, IO access may be associated with less favorable outcomes in terms of survival, neurological function, and ROSC compared to IV access. Further research is needed to address limitations and provide more robust evidence regarding the comparative effectiveness of intraosseous and intravenous access in this clinical setting.
Keywords: intra-osseous access, intravenous access, out-of-hospital cardiac arrest, spontaneous circulation, hospital discharge | | --- | | Introduction
Out-of-hospital cardiac arrest (OHCA) stands as a critical medical event with staggering mortality rates, necessitating swift and efficient interventions to enhance patient outcomes 1,2. Nurses are pivotal in OHCA management, offering indispensable care during the prehospital phase and facilitating the administration of medications and fluids.3 Among the crucial considerations for nurses in OHCA is the selection of vascular access, such as intraosseous (IO) or intravenous (IV) access, as it directly impacts the delivery of life-saving interventions.4–6 While the European Resuscitation Council (ERC) guidelines7 advocate for peripheral venous route utilization during cardiopulmonary resuscitation (CPR), they | Received: 2 July 2025 Accepted: 16 November 2025 Published: 30 December 2025 Therapeutics and Clinical Risk Management 2025:21 1887–1903 1887 © 2025 Cai and Dai. This

FAQs

What is the main objective of this systematic review?

To compare the safety and efficacy of intraosseous (IO) versus intravenous (IV) vascular access in out-of-hospital cardiac arrest (OHCA).

How many studies and patients were included, and which outcomes were assessed?

Twenty-three studies were included, comprising 48945 IO and 188966 IV cases. Outcomes included ROSC, survival to discharge, neurological outcome, comorbidities, and access time.

What were the key findings regarding neurological outcome and ROSC?

Favorable neurological outcome was similar between IO and IV overall. IO access was associated with lower odds of shockable rhythms, and pediatric OHCA showed lower ROSC with IO compared with IV.

Sep 28, 2026

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