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? 

                                                <a href="https://pubmed.ncbi.nlm.nih.gov/35129643/" target="_blank" rel="noopener">                         <img width="1492" height="676" src="https://criticalcarenow.com/wp-content/uploads/2022/03/Screen-Shot-2022-03-01-at-03.27.28.png" alt="" loading="lazy" />                                </a>     <p><b>What did they do?</b></p><ul><li style="font-weight: 400">Observational multicenter study of consecutive patients between 2011-2018 for post-resuscitation shock from out of hospital cardiac arrest (OHCA) registry</li><li style="font-weight: 400">Multi-center from five hospitals in France</li><li style="font-weight: 400">Post-resuscitation shock was defined as hypotension with a need for vasopressors for more than 6 hours despite adequate fluid loading</li><li style="font-weight: 400">Exclusion<ul><li style="font-weight: 400">Obvious extra-cardiac cause of cardiac arrest (trauma, drowning, drug overdose, electrocution, or asphyxia)</li><li style="font-weight: 400">Refractory cardiac arrest without sustainable return of ROSC</li><li style="font-weight: 400">Refractory shock requiring extracorporeal membrane oxygenation (ECMO)</li><li style="font-weight: 400">Absence of continuous IV treatment with epinephrine or norepinephrine</li><li style="font-weight: 400">Continuous IV treatment with both epinephrine and norepinephrine</li></ul></li><li style="font-weight: 400">Statistics<ul><li style="font-weight: 400">Primary outcome was all-cause mortality during hospital stay</li><li style="font-weight: 400">Secondary endpoint included cardiovascular-specific mortality, unfavorable neurological status at hospital discharge using the Cerebral Performance Category (CPC) score of 3-5</li></ul></li></ul><p dir="ltr">Results</p><ul><li><p dir="ltr" role="presentation">1,421 patients were identified in the database, but 766 were included in the final analysis after exclusion criteria were evaluated</p></li><li><p dir="ltr" role="presentation">481 (63%) were treated with norepinephrine and 285 (37%) with epinephrine</p></li><li><p dir="ltr" role="presentation">Demographics</p><ul><li><p dir="ltr" role="presentation">Median age: 64 years </p></li><li><p dir="ltr" role="presentation">Male: 73%</p></li><li><p dir="ltr" role="presentation">Median time from collapse to CPR was 5 minutes (IQR 1-10)</p></li><li><p dir="ltr" role="presentation">Median time from CPR to ROSC was 22 min (IQR 15-30)</p></li><li><p dir="ltr" role="presentation">Patients receiving epinephrine had a significantly lower blood pressure, higher lactate, and higher heart rate</p></li><li><p dir="ltr" role="presentation">Inotropic equivalent was also significantly higher in the epinephrine group vs. norepinephrine, 68 vs. 49 (p&lt;0.003), respectively</p></li></ul></li></ul><p> </p><ul><li><p dir="ltr" role="presentation">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)</p></li></ul><p> </p><ul><li><p dir="ltr" role="presentation">Secondary outcomes: </p><ul><li><p dir="ltr" role="presentation">Cardiovascular hospital mortality was also significantly higher in the epinephrine group (aOR 5.5l 95% CI 3-10.3; p &lt;0.001)</p></li><li><p dir="ltr" role="presentation">Unfavorable neurologic outcome was also higher in the epinephrine group (OR 3; 95% CI 1.6-5.7; p = 0.001)</p></li></ul></li></ul>                                                  <img width="1920" height="1080" src="https://criticalcarenow.com/wp-content/uploads/2021/12/Untitled-design-2.jpg" alt="" loading="lazy" />                                                            <p>Strengths</p><ul><li style="font-weight: 400">Large cohort with detailed analysis of variables, outcomes, and potential confounders</li></ul><p>Limitations</p><ul><li style="font-weight: 400">Observational study design leading to potential bias with selection of vasopressor and dose titration</li><li style="font-weight: 400">Numerous differences between patient groups including initial shockable rhythm, time from CPR to ROSC, myocardial dysfunction)</li></ul><p><b>The Debrief</b></p><ul><li style="font-weight: 400">Epinephrine was found to have a higher all-cause hospital mortality compared to norepinephrine for patients with post-resuscitation shock</li><li style="font-weight: 400">Norepinephrine may be the preferred vasopressor, but additional confirmatory evidence is needed</li></ul>                 <h2>PEER Reviewed by</h2>Seth Kelly, MD<h2>PEER Reviewed by</h2>MOHAMED HAGAHMED, MD<h2>PEER Reviewed by</h2>Kevin Yeh, PharmD