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

• Published in: The American journal of emergency medicine 2024-03, Vol.77, p.158-163
• Main Authors: Lawson, Christine K., Faine, Brett A., Rech, Megan A., Childs, Christopher A., Brown, Caitlin S., Slocum, Giles W., Acquisto, Nicole M., Ray, Lance
• Format: Article
• Language: English
• Subjects: Bias; Cardiac arrest; Cardiac arrhythmia; Catecholamines; Clinical outcomes; Creatinine; Emergency medical care; Epinephrine; Epinephrine - therapeutic use; Heart; Heart Arrest - drug therapy; Heart Arrest - mortality; Heart Arrest - therapy; Heart rate; Hemodynamics; Hemodynamics - drug effects; Hospital Mortality; Humans; Meta-analysis; Mortality; Norepinephrine; Norepinephrine - therapeutic use; Population; Post-resuscitation shock; Return of spontaneous circulation; Shock; Shock - drug therapy; Shock - etiology; Shock, Cardiogenic - drug therapy; Shock, Cardiogenic - etiology; Shock, Cardiogenic - mortality; Statistical analysis; Systematic review; Vasoconstrictor Agents - therapeutic use; Vasopressors
• ISSN: 0735-6757; 1532-8171; 1532-8171
• DOI: 10.1016/j.ajem.2023.12.031

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