Division of Critical Care, Department of Medicine, University of Ottawa, ON, Canada; Department of Emergency Medicine, University of Ottawa, ON, Canada; CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada.
Chest. 2023 Aug;164(2):381-393. doi: 10.1016/j.chest.2023.01.033. Epub 2023 Jan 31.
Epinephrine is the most commonly used drug in out-of-hospital cardiac arrest (OHCA) resuscitation, but evidence supporting its efficacy is mixed.
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?
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.
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 in those with shockable rhythm (OR, 0.85; 95% CI, 0.39-1.85).
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.
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肾上腺素是院外心脏骤停（OHCA）复苏中最常用的药物，但支持其疗效的证据参差不齐。
标准剂量肾上腺素、高剂量肾上腺素、肾上腺素加血管加压素与安慰剂或不治疗相比，在改善 OHCA 后结局方面的比较疗效和安全性如何？
在这项针对随机对照试验的系统评价和网络荟萃分析中，我们从六个数据库中检索了从成立到 2022 年 6 月的随机对照试验，评估了 OHCA 复苏期间使用肾上腺素的情况。我们进行了似然随机效应网络荟萃分析，并呈现了 OR 和 95%CI。我们使用推荐评估、制定与评价（GRADE）方法来评估证据的确定性。结局包括自主循环恢复（ROSC）、存活至入院、存活至出院和存活且功能结局良好。
我们纳入了 18 项试验（21594 名患者）。与安慰剂或不治疗相比，高剂量肾上腺素（OR，4.27；95%CI，3.68-4.97）、标准剂量肾上腺素（OR，3.69；95%CI，3.32-4.10）和肾上腺素加血管加压素（OR，3.54；95%CI，2.94-4.26）均增加了 ROSC。高剂量肾上腺素（OR，3.53；95%CI，2.97-4.20）、标准剂量肾上腺素（OR，3.00；95%CI，2.66-3.38）和肾上腺素加血管加压素（OR，2.79；95%CI，2.27-3.44）均增加了存活至入院的比例，但与安慰剂或不治疗相比，这些药物均未增加存活至出院或存活且功能结局良好的比例。与安慰剂或不治疗相比，标准剂量肾上腺素提高了无颤心律失常患者的出院存活率（OR，2.10；95%CI，1.21-3.63），但对有颤心律失常患者没有影响（OR，0.85；95%CI，0.39-1.85）。
标准剂量肾上腺素、高剂量肾上腺素和肾上腺素加血管加压素的使用增加了 ROSC 和存活至入院的比例，但可能不会改善存活至出院或功能结局。标准剂量肾上腺素提高了无颤心律失常患者的出院存活率，但对有颤心律失常患者没有影响。
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