(1506) Epinephrine vs Norepinephrine in Post-Cardiac Arrest Patients: Systematic Review and Meta-Analysis

Introduction: Post-resuscitation hypotension in patients who experience return of spontaneous circulation (ROSC) after cardiac arrest is a significant cause of morbidity and mortality. Currently, the standard practice is to continue with epinephrine infusion (EPI) after ROSC is achieved. Recent literature suggested that norepinephrine infusion (NE) may be more beneficial for patient outcome. The goal of this systematic review and meta-analysis is to assess the current level evidence comparing both modalities of treatment for patient outcome.

Methods: We searched PubMed, Scopus, EMBASE, and Cochrane from their inception through June 2024. Any observational or randomized studies involving adult patients, that compared a control group treated with EPI versus an intervention group treated with NE, were eligible. Only full text articles in English language were included. Outcomes were survival to discharge, rate of re-arrest during hospital stays, and favorable neurological condition at discharge (FNO). We used random-effects meta-analysis to compare the outcomes, Newcastle-Ottawa Scale, Cochrane Risk of Bias Tool for quality assessment. Heterogeneity between studies was assessed with the I2 value. We assessed publication bias using both Begg and Egger’s tests.

Results: After screening 1165 titles, 6 articles were analyzed. Five studies were observational studies, which all had high quality. One study was a randomized trial that had some concern for risk of bias. A total of 4488 patients, 2902 (65%) male were included. 2041 (45%) received NE while 2447 (55%) received EPI. Receiving NE was associated with similar odds of hospital survival (OR 1.92, 95% CI 0.92-4.03, p=0.083, I2 = 88%), FNO (OR 1.06, 95% CI 0.32-3.52, p=0.92), but lower odds of recurrent cardiac arrest (OR 0.47, 95% CI 0.24-0.92, p=0.028, I2=89%).There was low likelihood of publication bias for all 3 outcomes.

Conclusions: The use of NE post-ROSC is NOT associated with higher odds of survival to discharge or FNO but lower odds of recurrent arrest. Further studies are necessary to confirm our observation, due to high heterogeneity among the studies, including the implicit heterogeneity and number of observational studies included.