Baniowda, Muath

Establishing vascular access early in out-of-hospital cardiac arrest (OHCA) is a crucial factor for improving prognosis. Clinical guidelines recommend both intravascular (IV) and intraosseous (IO) access, but the superiority of one technique over the other has yet to be determined. Our review aimed to compare the efficacy and safety of IV versus IO access in OHCA. A comprehensive search was conducted on PubMed/MEDLINE, Embase, and Cochrane Library from inception till January 2025 for randomized controlled trials or their subgroup analyses comparing IV versus IO access in adult OHCA patients. The data for clinical outcomes were extracted, and forest plots were generated using the random-effects model in the Review Manager 5.4. We included 6 studies reporting data for 19,811 patients. The pooled analysis demonstrated that IO access had significantly higher odds of successful vascular access on first attempt [odds ratio (OR), 1.25; 95% confidence interval (CI), 0.19–0.34], but this did not translate to improved survival to hospital discharge (OR, 1.23; 95% CI, 0.90–1.67), survival to hospital discharge with a favorable neurological outcome (OR, 1.28; 95% CI, 0.93–1.76), and return of spontaneous circulation (OR, 1.13; 95% CI, 0.67–1.93). Intravenous and intraosseous vascular access have similar effects on clinical outcomes in patients with OHCA. The preferred method for vascular access should depend on the responder’s feasibility and expertise.

Background and objectives AKI is classified as prerenal, intrinsic, and postrenal. Prerenal AKI and intrinsic AKI represent the most common causes for AKI in hospitalized patients. This study aimed to examine the accuracy of the fractional excretion of sodium for distinguishing intrinsic from prerenal AKI. Design, setting, participants, & measurements We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, the Cochrane Library, and Scopus for all available studies that met the criteria until December 31, 2021. We included studies that evaluated fractional excretion of sodium in differentiating AKI etiologies in adults, whereas studies that did not have sufficient data to extract a 2×2 table were excluded. We assessed the methodologic quality using the Quality Assessment of Diagnostic Accuracy Studies-2 tool and extracted the diagnostic accuracy data for all included studies. We conducted a meta-analysis using the bivariate random effects model. We performed subgroup analysis to investigate sources of heterogeneity and the effect of the relevant confounders on fractional excretion of sodium accuracy. Results We included 19 studies with 1287 patients. In a subset of 15 studies (872 patients) that used a threshold of 1%, the pooled sensitivity and specificity for differentiating intrinsic from prerenal AKI were 90% (95% confidence interval, 81% to 95%) and 82% (95% confidence interval, 70% to 90%), respectively. In a subgroup of six studies (511 patients) that included CKD or patients on diuretics, the pooled sensitivity and specificity were 83% (95% confidence interval, 64% to 93%) and 66% (95% confidence interval, 51% to 78%), respectively. In five studies with 238 patients on diuretics, the pooled sensitivity and specificity were 80% (95% confidence interval, 69% to 87%) and 54% (95% confidence interval, 31% to 75%), respectively. In eight studies with 264 oliguric patients with no history of CKD or diuretic therapy, the pooled sensitivity and specificity were 95% (95% confidence interval, 82% to 99%) and 91% (95% confidence interval, 83% to 95%), respectively. Conclusions Fractional excretion of sodium has a limited role for AKI differentiation in patients with a history of CKD or those on diuretic therapy. It is most valuable when oliguria is present.