Intraosseous or Intravenous Vascular Access for Out-of-Hospital Cardiac Arrest
Mikael Fink Vallentin, Asger Granfeldt, Thomas Klitgaard, Søren Mikkelsen, Fredrik Folke, Helle Collatz Christensen, Amalie Ling Povlsen, Anne Karin Petersen, Sofie Winther, Lea Wildt Frilund, Carsten Meilandt, Mathias J. Holmberg, Kristian Blumensaadt Winther, Allan Bach, Thomas H. Dissing, Christian Juhl Terkelsen, Steffen Christensen, Line Kirkegaard Rasmussen, Lone Riis Mortensen, Mads Ladefoged Loldrup, Thomas Elkmann, Aida Nielsen, Charlotte Runge, Elise Klæstrup, Jimmy Højberg Holm, Mikkel Bak, Lars Peter Nielsen, Mette Abildgaard Pedersen, Gunhild Kjærgaard-Andersen, Peter M. Hansen, Anne Craveiro Brøchner, Erika Frischknecht Christensen, Frederik Mølgaard Nielsen, Christian G. Nissen, Jeppe W. Bjørn, Peter Burholt, Laust Emil Roelsgaard Obling, Sarah Louise Duus Holle, Lene Russell, Henrik Alstrøm, Søren Hestad, Tanja Hesse Fogtmann, Jens Hove Buciek, Karina Jakobsen, Mette Krag, Michael Sandgaard, Birthe Sindberg, Lars W. Andersen
Abstract
BACKGROUND: Out-of-hospital cardiac arrest is a leading cause of death worldwide. Establishing vascular access is critical for administering guideline-recommended drugs during cardiopulmonary resuscitation. Both the intraosseous route and the intravenous route are used routinely, but their comparative effectiveness remains unclear. METHODS: We conducted a randomized clinical trial to compare the effectiveness of initial attempts at intraosseous or intravenous vascular access in adults who had nontraumatic out-of-hospital cardiac arrest. The primary outcome was a sustained return of spontaneous circulation. Key secondary outcomes were survival at 30 days and survival at 30 days with a favorable neurologic outcome, defined by a score of 0 to 3 on the modified Rankin scale (scores range from 0 to 6, with higher scores indicating greater disability). RESULTS: Among 1506 patients who underwent randomization, 1479 were included in the primary analysis (731 in the intraosseous-access group and 748 in the intravenous-access group). The successful establishment of vascular access within two attempts occurred in 669 patients (92%) assigned to the intraosseous-access group and in 595 patients (80%) assigned to the intravenous-access group. Sustained return of spontaneous circulation occurred in 221 patients (30%) in the intraosseous-access group and in 214 patients (29%) in the intravenous-access group (risk ratio, 1.06; 95% confidence interval [CI], 0.90 to 1.24; P = 0.49). At 30 days, 85 patients (12%) in the intraosseous-access group and 75 patients (10%) in the intravenous-access group were alive (risk ratio, 1.16; 95% CI, 0.87 to 1.56); a favorable neurologic outcome at 30 days occurred in 67 patients (9%) and 59 patients (8%), respectively (risk ratio, 1.16; 95% CI, 0.83 to 1.62). Prespecified adverse events were uncommon. CONCLUSIONS: There was no significant difference in sustained return of spontaneous circulation between initial intraosseous and intravenous vascular access in adults who had out-of-hospital cardiac arrest. (Funded by the Novo Nordisk Foundation and others; IVIO EU Clinical Trials Register number, 2022-500744-38-00; ClinicalTrials.gov number, NCT05205031.).