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Epinephrine in out-of-hospital cardiac arrest – a network meta-analysis and subgroup analyses of shockable and non-shockable rhythms
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(2023) Epinephrine in out-of-hospital cardiac arrest – a network meta-analysis and subgroup analyses of shockable and non-shockable rhythms. Chest, 164 (2). pp. 381-393. doi:10.1016/j.chest.2023.01.033 ISSN 0012-3692.
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Official URL: https://doi.org/10.1016/j.chest.2023.01.033
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 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.
Item Type: | Journal Article | ||||||||
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Subjects: | Q Science > QP Physiology R Medicine > R Medicine (General) R Medicine > RC Internal medicine |
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Divisions: | Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Clinical Trials Unit Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School |
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Library of Congress Subject Headings (LCSH): | Adrenaline , Adrenaline -- Physiological effect, Cardiac arrest -- Treatment, Clinical trials | ||||||||
Journal or Publication Title: | Chest | ||||||||
Publisher: | Elsevier Inc | ||||||||
ISSN: | 0012-3692 | ||||||||
Official Date: | August 2023 | ||||||||
Dates: |
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Volume: | 164 | ||||||||
Number: | 2 | ||||||||
Page Range: | pp. 381-393 | ||||||||
DOI: | 10.1016/j.chest.2023.01.033 | ||||||||
Status: | Peer Reviewed | ||||||||
Publication Status: | Published | ||||||||
Access rights to Published version: | Restricted or Subscription Access | ||||||||
Copyright Holders: | Copyright © 2023 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. | ||||||||
Date of first compliant deposit: | 10 March 2023 | ||||||||
Date of first compliant Open Access: | 31 January 2024 | ||||||||
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