The Pre-brief
We have all been in the situation where we are relieved when a team member says they feel a pulse during CPR and we can begin post-ROSC care but then only to hear of an initial low blood pressure reading. So, you decide to start a vasopressor but which one: epinephrine or norepinephrine?
What did they do?
- Observational multicenter study of consecutive patients between 2011-2018 for post-resuscitation shock from out of hospital cardiac arrest (OHCA) registry
- Multi-center from five hospitals in France
- Post-resuscitation shock was defined as hypotension with a need for vasopressors for more than 6 hours despite adequate fluid loading
- Exclusion
- Obvious extra-cardiac cause of cardiac arrest (trauma, drowning, drug overdose, electrocution, or asphyxia)
- Refractory cardiac arrest without sustainable return of ROSC
- Refractory shock requiring extracorporeal membrane oxygenation (ECMO)
- Absence of continuous IV treatment with epinephrine or norepinephrine
- Continuous IV treatment with both epinephrine and norepinephrine
- Statistics
- Primary outcome was all-cause mortality during hospital stay
- Secondary endpoint included cardiovascular-specific mortality, unfavorable neurological status at hospital discharge using the Cerebral Performance Category (CPC) score of 3-5
Results
1,421 patients were identified in the database, but 766 were included in the final analysis after exclusion criteria were evaluated
481 (63%) were treated with norepinephrine and 285 (37%) with epinephrine
Demographics
Median age: 64 years
Male: 73%
Median time from collapse to CPR was 5 minutes (IQR 1-10)
Median time from CPR to ROSC was 22 min (IQR 15-30)
Patients receiving epinephrine had a significantly lower blood pressure, higher lactate, and higher heart rate
Inotropic equivalent was also significantly higher in the epinephrine group vs. norepinephrine, 68 vs. 49 (p<0.003), respectively
Primary outcome: All cause hospital mortality was significantly higher in the epinephrine group (OR 2.6; 95% CI 1.4-4.7; p = 0.002)
Secondary outcomes:
Cardiovascular hospital mortality was also significantly higher in the epinephrine group (aOR 5.5l 95% CI 3-10.3; p <0.001)
Unfavorable neurologic outcome was also higher in the epinephrine group (OR 3; 95% CI 1.6-5.7; p = 0.001)
Strengths
- Large cohort with detailed analysis of variables, outcomes, and potential confounders
Limitations
- Observational study design leading to potential bias with selection of vasopressor and dose titration
- Numerous differences between patient groups including initial shockable rhythm, time from CPR to ROSC, myocardial dysfunction)
The Debrief
- Epinephrine was found to have a higher all-cause hospital mortality compared to norepinephrine for patients with post-resuscitation shock
- Norepinephrine may be the preferred vasopressor, but additional confirmatory evidence is needed
