Norepinephrine versus epinephrine for hemodynamic support in post-cardiac arrest shock: A systematic review - 12/02/24

Doi : 10.1016/j.ajem.2023.12.031

Christine K. Lawson, Pharm.D. ^a,^{^⁎} , Brett A. Faine, Pharm.D., M.S. ^b, Megan A. Rech, Pharm.D., M.S. ^c, Christopher A. Childs, M.S. ^d, Caitlin S. Brown, Pharm.D. ^e, Giles W. Slocum, Pharm.D. ^f, Nicole M. Acquisto, Pharm.D. ^g, Lance Ray, Pharm.D. ^h,ⁱ
On behalf of the EMPHARM-NET Study Group
^a Department of Pharmacy, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903, USA
^b Department of Pharmacy and Department of Emergency Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Dr., Iowa City, IA 52242, USA
^c Department of Veteran Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, 5000 5th Ave., Hines, IL 60141, USA
^d Hardin Library for the Health Sciences, University of Iowa, 600 Newton Rd., Iowa City, IA 52242, USA
^e Department of Emergency Medicine and Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
^f Department of Emergency Medicine and Department of Pharmacy, Rush University Medical Center, 1653 W. Congress Parkway, Chicago, IL 60612, USA
^g Department of Emergency Medicine and Department of Pharmacy, University of Rochester Medical Center, 601 Elmwood Ave, Box 638, Rochester, NY 14642, USA
^h Department of Pharmacy, Denver Health and Hospital Authority, 790 Delaware St., MC 0056, Denver, CO 80204, USA
ⁱ Department of Emergency Medicine, University of Colorado, 13001 E 17th Pl., Aurora, CO 80045, USA

^⁎Corresponding author.

Abstract

Purpose

The preferred vasopressor in post-cardiac arrest shock has not been established with robust clinical outcomes data. Our goal was to perform a systematic review and meta-analysis comparing rates of in-hospital mortality, refractory shock, and hemodynamic parameters in post-cardiac arrest patients who received either norepinephrine or epinephrine as primary vasopressor support.

Methods

We conducted a search of PubMed, Cochrane Library, and CINAHL from 2000 to 2022. Included studies were prospective, retrospective, or published abstracts comparing norepinephrine and epinephrine in adults with post-cardiac arrest shock or with cardiogenic shock and extractable post-cardiac arrest data. The primary outcome of interest was in-hospital mortality. Other outcomes included incidence of arrhythmias or refractory shock.

Results

The database search returned 2646 studies. Two studies involving 853 participants were included in the systematic review. The proposed meta-analysis was deferred due to low yield. Crude incidence of in-hospital mortality was numerically higher in the epinephrine group compared with norepinephrine in both studies, but only statistically significant in one. Risk of bias was moderate to severe for in-hospital mortality. Additional outcomes were reported differently between studies, minimizing direct comparison.

Conclusion

The vasopressor with the best mortality and hemodynamic outcomes in post-cardiac arrest shock remains unclear. Randomized studies are crucial to remedy this.

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Keywords : Cardiac arrest, Return of spontaneous circulation, Post-resuscitation shock, Vasopressors, Catecholamines