Intravenous or Intraosseous Vascular Access in Cardiac Arrest: An Individual Participant Data Meta-Analysis

To perform a systematic review and individual participant data meta-analysis of randomized trials comparing intraosseous-first with intravenous-first vascular access during cardiac arrest.

The PRISMA-IPD guidelines were followed. We searched Medline, Embase, and the Cochrane Library on March 18, 2026, for individually randomized clinical trials. Pairs of investigators reviewed studies for relevance, extracted data, and assessed risk of bias. Individual participant data meta-analyses were conducted using logistic regression with adjustment for prognostic factors. Bayesian analyses were conducted using prespecified prior distributions. The certainty of evidence was evaluated using GRADE methodology.

Two randomized trials provided individual participant data for 7,561 patients with out-of-hospital cardiac arrest. There was no difference in 30-day survival (odds ratio, 1.01; 95% confidence interval, 0.81 to 1.25; moderate certainty of evidence) and favorable neurological outcome at 30 days or hospital discharge (odds ratio, 1.08; 95% confidence interval, 0.83 to 1.41; low certainty of evidence) between patients receiving intraosseous compared with intravenous vascular access. For sustained return of spontaneous circulation, the point estimate favored intravenous access (odds ratio, 0.90; 95% confidence interval, 0.81 to 1.01; low certainty of evidence), although the result was not statistically significant. Bayesian analyses found a high probability that any difference between the two strategies was small.

In this individual participant data meta-analysis of two randomized trials, intraosseous-first compared with intravenous-first vascular access during out-of-hospital cardiac arrest did not result in a statistically significant difference in 30-day survival, sustained return of spontaneous circulation, and favorable neurological outcome.