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Clinical Summary

For out-of-hospital cardiac arrest, epinephrine improves short-term outcomes: meta-analysis

Takeaway

  • For patients experiencing out-of-hospital cardiac arrest (OHCA), epinephrine in standard or high doses is tied to better short-term outcomes at hospital discharge, but not neurological outcomes.

Why this matters

  • Optimal epinephrine dosage during OHCA resuscitation is unknown.
  • This meta-analysis compares epinephrine vs placebo/no drugs, stratifies trials by fragility, and includes PARAMEDIC2.

Key results

  • Survival to discharge:
    • Standard-dose epinephrine (SDE) vs placebo/no drugs: relative risk (RR), 1.34 (95% CI, 1.08-1.67; P=.00).
    • Similar results in robust vs nonrobust trials.
    • SDE vs high-dose epinephrine (HDE) or SDE vs epinephrine+vasopressin: no difference.
  • Return of spontaneous circulation:
    • SDE vs placebo/no drugs: RR, 2.03 (95% CI, 1.18-3.51; P=.01).
    • SDE vs HDE: RR, 0.85 (95% CI, 0.74-0.97; P=.01).
  • Survival to admission:
    • SDE vs placebo/no drugs: RR, 2.04 (95% CI, 1.22-3.43; P=.00).
    • SDE vs HDE: RR, 0.86 (95% CI, 0.75-0.99; P=.04).
  • No comparator led to better neurological outcomes.

Study design

  • Systematic review, meta-analysis of 15 randomised controlled trials (n=20,716). 
  • Trials assessed epinephrine vs placebo or no drugs for treatment of adult OHCA.
  • Outcome: survival to hospital discharge.
  • Funding: None.

Limitations

  • Prospective and retrospective studies excluded.
  • Fragility index exceeded 0 in only 3 trials, suggesting that only a few patients with different outcomes would have changed the conclusions.

References


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