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Fernando SM, Mathew R, Sadeghirad B, Rochwerg B, Hibbert B, Munshi L, Fan E, Brodie D, Di Santo P, Tran A, McLeod SL, Vaillancourt C, Cheskes S, Ferguson ND, Scales DC, Lin S, Sandroni C, Soar J, Dorian P, Perkins GD, Nolan JP. Epinephrine in Out-of-Hospital Cardiac Arrest: A Network Meta-analysis and Subgroup Analyses of Shockable and Nonshockable Rhythms. Chest 2023; 164:381-393. [PMID: 36736487 DOI: 10.1016/j.chest.2023.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/20/2023] [Accepted: 01/21/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Epinephrine is the most commonly used drug in out-of-hospital cardiac arrest (OHCA) resuscitation, but evidence supporting its efficacy is mixed. RESEARCH QUESTION What are the comparative efficacy and safety of standard dose epinephrine, high-dose epinephrine, epinephrine plus vasopressin, and placebo or no treatment in improving outcomes after OHCA? STUDY DESIGN AND METHODS In this systematic review and network meta-analysis of randomized controlled trials, we searched six databases from inception through June 2022 for randomized controlled trials evaluating epinephrine use during OHCA resuscitation. We performed frequentist random-effects network meta-analysis and present ORs and 95% CIs. We used the the Grading of Recommendations, Assessment, Development, and Evaluation approach to rate the certainty of evidence. Outcomes included return of spontaneous circulation (ROSC), survival to hospital admission, survival to discharge, and survival with good functional outcome. RESULTS We included 18 trials (21,594 patients). Compared with placebo or no treatment, high-dose epinephrine (OR, 4.27; 95% CI, 3.68-4.97), standard-dose epinephrine (OR, 3.69; 95% CI, 3.32-4.10), and epinephrine plus vasopressin (OR, 3.54; 95% CI, 2.94-4.26) all increased ROSC. High-dose epinephrine (OR, 3.53; 95% CI, 2.97-4.20), standard-dose epinephrine (OR, 3.00; 95% CI, 2.66-3.38), and epinephrine plus vasopressin (OR, 2.79; 95% CI, 2.27-3.44) all increased survival to hospital admission as compared with placebo or no treatment. However, none of these agents may increase survival to discharge or survival with good functional outcome as compared with placebo or no treatment. Compared with placebo or no treatment, standard-dose epinephrine improved survival to discharge among patients with nonshockable rhythm (OR, 2.10; 95% CI, 1.21-3.63), but not in those with shockable rhythm (OR, 0.85; 95% CI, 0.39-1.85). INTERPRETATION Use of standard-dose epinephrine, high-dose epinephrine, and epinephrine plus vasopressin increases ROSC and survival to hospital admission, but may not improve survival to discharge or functional outcome. Standard-dose epinephrine improved survival to discharge among patients with nonshockable rhythm, but not those with shockable rhythm. TRIAL REGISTRY Center for Open Science: https://osf.io/arxwq.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, ON, Canada; Department of Emergency Medicine, University of Ottawa, ON, Canada; CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Rebecca Mathew
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Behnam Sadeghirad
- Department of Anesthesia, Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence, and Impact, Department of Medicine, McMaster University, Hamilton, ON, Canada; Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Benjamin Hibbert
- Department of Cellular and Molecular Medicine, University of Ottawa, ON, Canada; CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, ON, Canada; Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, ON, Canada; Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY
| | - Pietro Di Santo
- Division of Critical Care, Department of Medicine, University of Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, ON, Canada; CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Alexandre Tran
- Division of Critical Care, Department of Medicine, University of Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, ON, Canada
| | - Shelley L McLeod
- Department of Health Research Methods, Evidence, and Impact, Department of Medicine, McMaster University, Hamilton, ON, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada
| | - Christian Vaillancourt
- Department of Emergency Medicine, University of Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sheldon Cheskes
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, ON, Canada; Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Steve Lin
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Claudio Sandroni
- Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, England
| | - Paul Dorian
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, Warwick University, Gibbet Hill, Coventry, England
| | - Jerry P Nolan
- Warwick Clinical Trials Unit, Warwick Medical School, Warwick University, Gibbet Hill, Coventry, England; Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, England
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Abstract
BACKGROUND Adrenaline and vasopressin are widely used to treat people with cardiac arrest, but there is uncertainty about the safety, effectiveness and the optimal dose. OBJECTIVES To determine whether adrenaline or vasopressin, or both, administered during cardiac arrest, afford any survival benefit. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase and DARE from their inception to 8 May 2018, and the International Liaison Committee on Resuscitation 2015 Advanced Life Support Consensus on Science and Treatment Recommendations. We also searched four trial registers on 5 September 2018 and checked the reference lists of the included studies and review papers to identify potential papers for review. SELECTION CRITERIA Any randomised controlled trial comparing: standard-dose adrenaline versus placebo; standard-dose adrenaline versus high-dose adrenaline; and adrenaline versus vasopressin, in any setting, due to any cause of cardiac arrest, in adults and children. There were no language restrictions. DATA COLLECTION AND ANALYSIS Two review authors independently identified trials for review, assessed risks of bias and extracted data, resolving disagreements through re-examination of the trial reports and by discussion. We used risk ratios (RRs) with 95% confidence intervals (CIs) to compare dichotomous outcomes for clinical events. There were no continuous outcomes reported. We examined groups of trials for heterogeneity. We report the quality of evidence for each outcome, using the GRADE approach. MAIN RESULTS We included 26 studies (21,704 participants).Moderate-quality evidence found that adrenaline increased survival to hospital discharge compared to placebo (RR 1.44, 95% CI 1.11 to 1.86; 2 studies, 8538 participants; an increase from 23 to 32 per 1000, 95% CI 25 to 42). We are uncertain about survival to hospital discharge for high-dose compared to standard-dose adrenaline (RR 1.10, 95% CI 0.75 to 1.62; participants = 6274; studies = 10); an increase from 33 to 36 per 1000, 95% CI 24 to 53); standard-dose adrenaline versus vasopressin (RR 1.25, 95% CI 0.84 to 1.85; 6 studies; 2511 participants; an increase from 72 to 90 per 1000, 95% CI 60 to 133); and standard-dose adrenaline versus vasopressin plus adrenaline (RR 0.76, 95% CI 0.47 to 1.22; 3 studies; 3242 participants; a possible decrease from 24 to 18 per 1000, 95% CI 11 to 29), due to very low-quality evidence.Moderate-quality evidence found that adrenaline compared with placebo increased survival to hospital admission (RR 2.51, 95% CI 1.67 to 3.76; 2 studies, 8489 participants; an increase from 83 to 209 per 1000, 95% CI 139 to 313). We are uncertain about survival to hospital admission when comparing standard-dose with high-dose adrenaline, due to very low-quality evidence. Vasopressin may improve survival to hospital admission when compared with standard-dose adrenaline (RR 1.27, 95% CI 1.04 to 1.54; 3 studies, 1953 participants; low-quality evidence; an increase from 260 to 330 per 1000, 95% CI 270 to 400), and may make little or no difference when compared to standard-dose adrenaline plus vasopressin (RR 0.95, 95% CI 0.83 to 1.08; 3 studies; 3249 participants; low-quality evidence; a decrease from 218 to 207 per 1000 (95% CI 181 to 236).There was no evidence that adrenaline (any dose) or vasopressin improved neurological outcomes.The rate of return of spontaneous circulation (ROSC) was higher for standard-dose adrenaline versus placebo (RR 2.86, 95% CI 2.21 to 3.71; participants = 8663; studies = 3); moderate-quality evidence; an increase from 115 to 329 per 1000, 95% CI 254 to 427). We are uncertain about the effect on ROSC for the comparison of standard-dose versus high-dose adrenaline and standard-does adrenaline compared to vasopressin, due to very low-quality evidence. Standard-dose adrenaline may make little or no difference to ROSC when compared to standard-dose adrenaline plus vasopressin (RR 0.97, 95% CI 0.87 to 1.08; 3 studies, 3249 participants; low-quality evidence; a possible decrease from 299 to 290 per 1000, 95% CI 260 to 323).The source of funding was not stated in 11 of the 26 studies. The study drugs were provided by the manufacturer in four of the 26 studies, but neither drug represents a profitable commercial option. The other 11 studies were funded by organisations such as research foundations and government funding bodies. AUTHORS' CONCLUSIONS This review provides moderate-quality evidence that standard-dose adrenaline compared to placebo improves return of spontaneous circulation, survival to hospital admission and survival to hospital discharge, but low-quality evidence that it did not affect survival with a favourable neurological outcome. Very low -quality evidence found that high-dose adrenaline compared to standard-dose adrenaline improved return of spontaneous circulation and survival to admission. Vasopressin compared to standard dose adrenaline improved survival to admission but not return of spontaneous circulation, whilst the combination of adrenaline and vasopressin compared with adrenaline alone had no effect on these outcomes. Neither standard dose adrenaline, high-dose adrenaline,vasopressin nor a combination of adrenaline and vasopressin improved survival with a favourable neurological outcome. Many of these studies were conducted more than 20 years ago. Treatment has changed in recent years, so the findings from older studies may not reflect current practice.
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Affiliation(s)
- Judith Finn
- Curtin UniversityPrehospital, Resuscitation and Emergency Care Research Unit (PRECRU)Kent StreetBentleyWestern AustraliaAustralia6102
- St John Ambulance Western AustraliaBelmontAustralia
| | - Ian Jacobs
- Curtin UniversityPrehospital, Resuscitation and Emergency Care Research Unit (PRECRU)Kent StreetBentleyWestern AustraliaAustralia6102
- St John Ambulance Western AustraliaBelmontAustralia
| | | | - Simon Gates
- University of BirminghamCancer Research UK Clinical Trials Unit, School of Cancer Sciences, Institute of Cancer and Genomic SciencesBirminghamUKB15 2TT
| | - Gavin D Perkins
- University of WarwickWarwick Medical School and University Hospitals BirminghamCoventryUK
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