A comparison of epinephrine and norepinephrine in critically ill patients

• Published in: Intensive care medicine 2008-12, Vol.34 (12), p.2226-2234
• Main Authors: Myburgh, John A., Higgins, Alisa, Jovanovska, Alina, Lipman, Jeffrey, Ramakrishnan, Naresh, Santamaria, John
• Format: Article
• Language: English
• Subjects: Aged; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Anesthesiology; Biological and medical sciences; Blood Pressure; Clinical death. Palliative care. Organ gift and preservation; Critical Care Medicine; Critical Illness; Double-Blind Method; Emergency Medicine; Epinephrine - therapeutic use; Female; Humans; Hypotension - drug therapy; Intensive; Intensive care; Intensive care medicine; Intensive Care Units; Kaplan-Meier Estimate; Male; Medical sciences; Medicine; Medicine & Public Health; Middle Aged; Mortality; Norepinephrine - therapeutic use; Original; Pain Medicine; Patients; Pediatrics; Pneumology/Respiratory System; Sepsis; Shock, Septic - drug therapy; Vasoconstrictor Agents - therapeutic use
• ISSN: 0342-4642; 1432-1238
• DOI: 10.1007/s00134-008-1219-0

Objective To determine whether there was a difference between epinephrine and norepinephrine in achieving a mean arterial pressure (MAP) goal in intensive care (ICU) patients. Design Prospective, double-blind, randomised-controlled trial. Setting Four Australian university-affiliated multidisciplinary ICUs. Patients and participants Patients who required vasopressors for any cause at randomisation. Patients with septic shock and acute circulatory failure were analysed separately. Interventions Blinded infusions of epinephrine or norepinephrine to achieve a MAP ≥70 mmHg for the duration of ICU admission. Measurements Primary outcome was achievement of MAP goal >24 h without vasopressors. Secondary outcomes were 28 and 90-day mortality. Two hundred and eighty patients were randomised to receive either epinephrine or norepinephrine. Median time to achieve the MAP goal was 35.1 h (interquartile range (IQR) 13.8–70.4 h) with epinephrine compared to 40.0 h (IQR 14.5–120 h) with norepinephrine (relative risk (RR) 0.88; 95% confidence interval (CI) 0.69–1.12; P  = 0.26). There was no difference in the time to achieve MAP goals in the subgroups of patients with severe sepsis ( n  = 158; RR 0.81; 95% CI 0.59–1.12; P  = 0.18) or those with acute circulatory failure ( n  = 192; RR 0.89; 95% CI 0.62–1.27; P  = 0.49) between epinephrine and norepinephrine. Epinephrine was associated with the development of significant but transient metabolic effects that prompted the withdrawal of 18/139 (12.9%) patients from the study by attending clinicians. There was no difference in 28 and 90-day mortality. Conclusions Despite the development of potential drug-related effects with epinephrine, there was no difference in the achievement of a MAP goal between epinephrine and norepinephrine in a heterogenous population of ICU patients.