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Wang D, Deng L, Zhang R, Zhou Y, Zeng J, Jiang H. Efficacy of intraosseous access for trauma resuscitation: A systematic review
and meta-analysis. World Journal of Emergency Surgery. 2023;18(1). doi:10.1186/s13017-023-00487-7

Efficacy of Intraosseous Access for Trauma Resuscitation:
A Systematic Review and Meta‑analysis


  • To assess the efficacy of intraosseous (IO) access compared to intravenous (IV) access in prehospital care of trauma patients.

This systematic review investigated the efficacy of IO access compared to IV in trauma patients receiving care in prehospital and emergency department settings. PubMed, Embase, ScienceDirect, Web of Science, the Cochrane Library, Banque de données en santé publique (BDSP), and Chinese National Knowledge Infrastructure (CNKI) databases were used to search for articles published between January 1, 2000 and January 31, 2023, about IO access use in severe trauma patients, regardless of their region, race, or nationality. Randomized controlled trials (RCTs), cohort studies, and case-control studies were included. Duplicate articles, animal studies, case reports, conference papers, cadaveric experiments, before-and-after studies, studies with missing data, and those lacking comparison data were excluded. Three reviewers independently screened the studies according to the inclusion and exclusion criteria, performed quality assessment (using the Newcastle-Ottawa scale [NOS] for non-RCT studies and the modified Jadad’s score for RCTs), and conducted a sensitivity analysis of the extracted literature. Two reviewers assessed the risk of publication bias using the Cochrane risk of bias (RoB-1 tool) for RCTs and the ROBINS-I tool for non-RCT studies. 

The GRADE approach was used to evaluate the quality of evidence and confidence in the outcomes; the Review Manager software (Version 5.4) was used for data analysis.


The primary outcome was success rate on initial access attempt (defined as secure needle placement in the marrow or peripheral vein with normal fluid flow). Secondary outcomes were mean procedure time (which included the time from kit opening to secured device placement and aspiration of venous blood or marrow from the attached tubing), mean time to resuscitation (defined as time from successful device placement to blood pressure recovery), and complications.


Of 1,326 retrieved records, a total of 8 studies (2 from the USA and 6 from China, published between 2007-2022) met the eligibility criteria and were included in the meta-analysis. Of these, 5 were RCTs involving 548 patients and 3 were cohort studies comprising 291 patients. A random-effects meta-analysis model was used for all four outcomes because the observed estimates of treatment effect varied across studies (ranging from 77% to 100%) due to real differences in the treatment effect in each study, as well as sampling variability (chance).

Table 2. Summary of Detailed Information About the Included Studies

IQR Interquartile range, RCT Randomized controlled trial, USA United States, I/C intervention group/comparison group

Tables recreated from original article

Cumulative analysis among studies comparing outcome measures between IO access and IV access showed that success rate on first attempt (reported by three RCTs and two prospective cohort studies) was significantly higher for IO (n=185) compared to IV (n=232) (relative risk [RR]=1.46, 95% CI [1.16, 1.85]; P=0.001); mean procedure time (reported by four RCTs and one retrospective cohort study) was significantly shorter for IO (n=279) vs. IV (n=293) (mean difference=-5.67, 95% CI [-9.26, -2.07]; P=0.02); and mean time to resuscitation (reported by three RCTs and one

retrospective cohort study) was equivalent between IO (n=239) and IV (n=253) (mean difference=-1.00, 95% CI [-3.18, 1.17]; P=0.37). There were no statistical differences between IO (n=314) and IV (n=375) in complication rates reported by six studies (RR=1.22, 95% CI [0.14, 10.62]; P=0.86). The most commonly reported complication was extravasation. Other complications included bone injury, soft tissue necrosis, osteomyelitis, and osteofascial compartment syndrome. No complications occurred in two of the studies.

Figure 5
Figure 6
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Figure 8

Funnel plots used to evaluate publication bias (i.e., publication of study results based on the direction or significance of the findings) were symmetrical for all outcomes, indicating no such bias was found. Sensitivity analysis performed to assess the stability of the pooled estimates, showed that excluding individual studies did not impact pooled results, except for complications, where the exclusion of one study changed the outcome compared to the pooled results. The overall quality of evidence and strength of the pooled data on all four outcomes was considered moderate.

The study has several limitations. First, large-scale RCTs were lacking. Second, the included studies had substantial heterogeneity among methodology, definitions, and patient selection. Third, the strength of the evidence on all four outcomes was moderate. Lastly, there was no comparison of survival outcomes between IO and IV.

The authors concluded that IO access demonstrated a significantly higher success rate on first attempt and significantly faster insertion time with an equivalent rate of complications. IO should be considered for urgent vascular access in hypotensive trauma patients, particularly those in severe shock. Due to major limitations, these findings should be interpreted with caution and need to be further validated with high-quality large, RCTs or prospective cohort studies.


The authors concluded that:

  • IO had a substantially higher first-attempt success rate compared to IV
  • IO had a significantly shorter procedure time than IV
  • Time to resuscitation was equivalent between IO and IV
  • IO had a comparable complication rate to IV
  • IO should be considered for emergent vascular access
    in hypotensive trauma patients, particularly those in
    severe shock
  • Due to significant limitations, study findings must be
    interpreted cautiously and further validated by large
    randomized controlled trials (RCT) and cohort studies
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Tables and figures recreated from original article


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