Abstract
Aim
To systematically review the literature on the use of vasopressors during adult cardiac
arrest to inform an update of international guidelines.
Methods
PRISMA guidelines were followed. We searched Medline, Embase, Web of Science, CINAHL,
and the Cochrane Library for controlled trials and observational studies. The population
included adults with cardiac arrest in any setting. Pairs of investigators reviewed
studies for relevance, extracted data, and assessed the risk of bias for individual
studies. Certainty of evidence was evaluated using GRADE for controlled trials and
meta-analyses were performed when at least two studies could be pooled.
Results
We included 15 controlled trials and 67 observational studies. The majority of studies
included out-of-hospital cardiac arrest only. Meta-analyses were performed for two
controlled trials comparing epinephrine to placebo, three comparing vasopressin to
epinephrine, and three comparing epinephrine plus vasopressin to epinephrine only.
All controlled trials ranged between low to some concern in risk of bias. The certainty
of evidence ranged from very low to high. Risk of bias for observational studies was
generally critical or serious, largely due to confounding and selection bias.
Conclusions
Controlled trial data suggest that epinephrine improves return of spontaneous circulation,
survival to hospital discharge, and 3-month survival in out-of-hospital cardiac arrest.
The improvement in short-term outcomes appeared more pronounced for non-shockable
rhythms. Differences in long-term neurological outcome did not reach statistical significance,
although there was a signal toward improved outcomes. Controlled trial data indicated
no benefit from vasopressin with or without epinephrine compared to epinephrine only.
Keywords
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Article info
Publication history
Published online: April 10, 2019
Accepted:
April 4,
2019
Received in revised form:
April 3,
2019
Received:
March 17,
2019
Identification
Copyright
© 2019 Elsevier B.V. All rights reserved.
