UMEM Educational Pearls

Title: Risk of arrhythmia in post-resuscitative shock after out-of-hospital cardiac arrest with epinephrine versus norepinephrine

Posted: 3/12/2024 by Quincy Tran, MD, PhD (Updated: 11/21/2024)
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Background: There is no clear guidelines regarding whether norepinephrine or epinephrine would be the preferred agent to maintain hemodynamic stability after cardiac arrest. In recent years, there has been more opinions about the use of norepinephrine in this situation.

Settings: retrospective multi-site cohort study of adult patients who presented to emergency departments at Mayo Clinic hospitals in Minnesota, Florida, Arizona with out-of-hospital-cardiac arrest (OHCA). Study period was May 5th, 2018, to January 31st, 2022

Participants: 18 years of age and older

Outcome measurement: tachycardia, rate of re-arrest during hospitalization, in-hospital mortality.

Multivariate logistic regressions were performed.

Study Results:

The study included 221 patients, 151 patients received norepinephrine infusion vs. 70 patients received epinephrine infusion.
The maximum dose of epinephrine = 0.28 mcg/kg/min vs. 0.15 mcg/kg/min for norepinephrine.
The Odds for clinically significant tachyarrhythmia was the same between both groups (OR 1.34, 95% CI 0.6802.62, P=0.40).
Epinephrine infusion was associated with higher odds of in-hospital mortality (OR 6.21, 95% CI 2.37–16.25, P <0.001)
Epinephrine infusion was associated with higher odds of re-arrest ( OR 5.77, 95% CI 2.74–12.18, P < 0.001)

Discussion:

It was retrospective study that uses electronic health records. Thus, other important factors from the pre-hospital settings might not be accurate.

On the other hand, the patient population came from multiple hospitals with varying practices so the patient population is more generalizable.

Conclusion:

Although the rate of tachyarrhythmia was not different between patients receiving norepinephrine vs. epinephrine after ROSC. This study would add more data to the current literature that norepinephrine might be more beneficial for patients with post-cardiac arrest shock.

References

Normand S, Matthews C, Brown CS, Mattson AE, Mara KC, Bellolio F, Wieruszewski ED. Risk of arrhythmia in post-resuscitative shock after out-of-hospital cardiac arrest with epinephrine versus norepinephrine. Am J Emerg Med. 2024 Mar;77:72-76. doi: 10.1016/j.ajem.2023.12.003. Epub 2023 Dec 10. PMID: 38104386.