EvidenceAlerts

OBJECTIVES: Patients who obtain return of spontaneous circulation (ROSC) after cardiac arrest often experience post-resuscitation hypotension, typically managed with epinephrine (EPI). However, recent research suggests that norepinephrine (NE) may improve patient outcomes. This systematic review and meta-analysis evaluates the effectiveness of EPI versus NE in managing post-resuscitative shock in patients who achieve ROSC.

METHODS: A systematic literature search in PubMed, Medline, Scopus, EMBASE, and Cochrane CENTRAL was performed. Observational or randomized studies on adults comparing EPI to NE after cardiac arrest were included in analysis. Outcomes were analyzed via random-effects meta-analysis and included rate of re-arrest during hospital stay, survival to discharge, and functional neurological outcome at discharge.

RESULTS: After screening 1217 studies, we analyzed 6 studies, which involved 3458 patients, with mean (+/- SD) age of 64 (+/- 3) years, and 2188 (63 %) were male. The NE group consisted of 1833 (53 %) patients and 287 (41 %) of the total 703 re-arrest. Patients receiving NE were associated with 63 % lower odds of having recurrent arrest (OR 0.47, 95 % CI 0.24-0.92, P = 0.03, I2 = 89 %). There was no statistical difference for rates of hospital survival (OR 2.04, 95 % 0.93-4.47) or discharge with unfavorable neurological outcome (OR 1.72, 95 % CI 0.92-3.22).

CONCLUSIONS: Among a small number of studies, norepinephrine use in post-cardiac arrest patients was associated with lower odds of recurrent cardiac arrest. However, high study heterogeneity highlights the need for well-designed future research to validate these findings.

Emergency Medicine rater

This meta-analysis includes only one RCT (n=40). The other five studies are observational. I question the value of undertaking meta-analyses of observational studies and produce a more precise but biased estimate of effectiveness.

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