Epinephrine in Cardiac Arrest Systematic Review and Meta-analysis

ane Introduction

Cardiac arrest was the most serious medical incidents with an estimated incidence in the United States of 95.7 per 100,000 person years,^[1,two] it is a swell challenge for cardiovascular physicians and emergency physicians. For more than 50 years, treatment strategies take included the apply of various drugs, just at that place is limited evidence that such treatments are effective.^[3] Early on in 1960 southward brute study revealed that epinephrine improved coronary and cerebral perfusion, improving a return of spontaneous circulation (ROSC) through the constriction of arterioles mediated past α-adrenergic receptors.^[4–6] Only for all this, potentially harmful effects on the eye atomic number 82 to greater myocardial oxygen need through β-adrenergic receptors and beal recurrent cardiac arrest.^[seven] Therefore, information technology makes sense to investigate the part of epinephrine in out-of-infirmary cardiac arrest (OHCA).

In previous studies they considered epinephrine did improve ROSC with out of infirmary cardiac arrest, merely exasperate the neurologic outcome.^[eight] In addition, Belletti^[nine] deemed just a combination of adrenaline, vasopressin, and methylprednisolone was associated with improved survival with a proficient neurologic issue compared with any other drug or placebo. However, Perkins^[x] considered that there was no significant difference in the rate of a favorable neurologic outcomes. Myocardial dysfunction, impaired cerebral micro-circulation, increase in ventricular arrhythmia, and increased oxygen consumption are likewise still non-negligible.^[xi–14]

Until at present, evidence in humans is limited, with near studies being observational studies with inconsistent results on short term outcomes including ROSC or hospital admission and long term outcomes including hospital discharge.^[15–17]

Despite several systematic reviews^[nine,18,19] have been published, in that location is still a need for further discussion and assay on account of some reasons every bit followed. 1 earlier research Lin^[18] implemented a systematic review that included randomized controlled trial (RCT), in that study their major purpose was to compare standard doses of epinephrine with another drugs that are placebo, vasopressin and loftier dosage of adrenaline in out of hospital cardiac arrest patients. Respect to the pool of adrenaline and no adrenaline administration in that location was simply one RCT^[20] included, fifty-fifty they failed to find any advantages of adrenaline over placebo, adrenaline and vasopressin combination, or vasopressin alone, in survival to belch or neurological outcomes after OHCA. Finally, not long ago Belletti^[9] conducted a network meta-assay and considered there was no significant randomized evidence to back up neither discourage the use of adrenaline during cardiac arrest.

Recently increasing literature have been implemented after the aforementioned studies. Hence, nosotros perform a systematic review and meta-assay which places emphasis on comparison epinephrine with placebo in several respects (such as, ROSC, hospital admission, hospital discharge and cerebral performance category (CPC) i or two) for the patients in out of infirmary cardiac arrest.

2 Materials and methods

Ethical approval or patient consent was not required because the present report was a review of previous published literature.

2.1 Searching strategy

The following ways were used to search all the literature. We performed medical subject heading (MeSH) and key words, such every bit "Center Arrest" (mesh), "Center Arrest" (title/abstract), "cardiac arrest"(title/abstract), these words were in conjunction with "epinephrine"(mesh), "epinephrine" (title/abstruse), "adrenaline" (title/abstract). In addition we performed the same similar words almost epinephrine and cardiac arrest those belonged to the same pregnant with unlike description blazon. In this fashion, we searched from PubMed, EMBASE and Cochrane library to confirm the relevant studies. These words were connected with AND or OR. Besides, nosotros searched the correlative article to assess whether was available to the current report. (Fig. 1)

Figure 1:

Catamenia diagram showing the option of randomized controlled trials.

2.2 Selection criteria

Two authors (Lu Huan and Fei Qin) screened the searching studies repeatedly, if they had divergences, some other person would reassess it. Any RCT published in English was included if it met the following selection criteria: first of all, the studies should exist RCTs; all the articles in patients with OCHA, compared concerns between epinephrine and no administration, and had ane or more outcomes of interest: ROSC, hospital admission, infirmary discharge, favorable neurologic outcome at hospital belch or cerebral performance category (CPC) one or 2, CPC scores are divers equally: I–normal role, II–mild to moderate disability, Three–severe inability, 4–vegetative country, and Five–dead.^[xx]; maybe in some literature they didn't perform epinephrine but the pregnant was equally aforementioned every bit epinephrine, we also included it.

2.3 Data extraction

The data which was based on a standardized collection was extracted by two independent reviewers (Lu Huan and Fei Qin). If the pattern of study belonged non-RCT, we would exclude. The following data were our collection: the year of publication, mean age year, number of patients. In improver, clinical data including initial cardiac rhythms, dose and routes of adrenaline assistants, presumed cardiac etiologies. Any divergence was discussed with the senior author (Yin Wu).

ii.iv Evaluation of quality

The evaluation of quality was according to the Cochrane Handbook. We performed depression, high and unclear to assess the quality in vii pools which included random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcomes cess, incomplete consequence data, selective outcome reporting and other sources of bias. (Figs. 2 and three)

Figure 2:

Risk bias of graph. Each risk of bias detail presented equally percentages beyond all of the included trials, which indicated the proportion of different level risk of bias for each item.

Effigy iii:

Risk bias of summary. Judgments about each run a risk of bias detail for each included trials. Greenish indicates low gamble of bias. Yellow indicates unclear gamble of bias. Ruby-red indicates high risk of bias.

2.five Data synthesis and statistical analysis

We performed STATA software to complete all the data synthesis, except for that applied the Review Manager 5 software to assess the quality of including studies. In the outcomes of interest, they belonged to dichotomous variables which were described equally risk ratio (RR) along with its 95% conviction interval (CI) and the furnishings pooled using a random effects model or fixed effects model that was based on their own heterogeneity for the primary and secondary outcomes. When Iⁱⁱ levels was less than or equal to 25% when it was regarded as depression, the I^two ranged between 25% and 50% when it was moderate, the I² levels was greater than 50% when it was high.^[21] The RR was pooled across studies applying the random-effect model if heterogeneity was present,^[22] otherwise a stock-still-effects model was performed. When the grade of heterogeneity was loftier, nosotros used random-furnishings model, to test the heterogeneity which represented the proportion of between study variation 2 researchers (Fei Qin and Lu Huan) independently affiliated the information into Stata, this is variation due to differences in written report design, interventions, or populations.

Nosotros analyzed the influence of each study to confirm the heterogeneity or to reassess the stable of primary outcome and used Egger exam to assess the publication bias. A sensitivity analysis was practical by excluding candidate studies suspected to be a source of heterogeneity or by Galbraith plot for heterogeneity performed by STATA. Owning to the number of including studies was < 10, there was no funnel plot in each puddle.

3 Event

3.1 Characteristics of included studies

There were only iv studies^{[10,20,23,24]} that satisfied criteria for inclusion in the systematic review and meta-analysis. Of these, all of them were RCTs. The flow of the search process and inclusion of studies is shown in Figure 1. Details regarding each written report are provided in Table 1. Among these studies included with 9061 patients, everyone reported survival to discharge that was primary outcome, three studies^[10,20,23] reported ROSC, infirmary admission and discharged with CPC one or 2. But One RCT^[24] included patients with both in-hospital and OHCA, we yet included it to pool effects of epinephrine and focused on the heterogeneity and the influence of each study.

Tabular array 1:

Characteristics of included studies.

3.2 Survival to discharge

All the studies^{[ten,xx,23,24]} included were applied for polling furnishings of adrenaline administration on survival to discharge. The pooled RR was i.40 (95% CI: 1.09, i.80) with a moderate degree of heterogeneity (I² = 36.3%, P = .008). (Fig. four) There was no evidence of publication bias as suggested by Egger test (P = .456 > 0.05). This demonstrated that receiving epinephrine had a college chance of discharge alive, despite this was of borderline significance. In improver, we performed an analysis to confirm the influence of individual study, all the spots located in 95% CI. (Fig. five)

Effigy 4:

Woods plots of survival to discharge in patients with epinephrine therapy vs those without epinephrine administration for OHCA.

Effigy five:

A analysis of private study was to confirm the influence of each report for the result, all the spots located in 95% CI.

3.iii Render of spontaneous circulation

Three of all studies^[10,20,23] were included for pooling epinephrine administration effects on ROSC with sample sizes of 4388 for epinephrine and 4334 for non-epinephrine groups. The heterogeneous was low across studies (I² = 23.ane%, P = .0001). A fixed-effects model was applied and generated a pooled RR of 3.05 (95% CI: ii.79, 3.34), suggesting that patients receiving epinephrine were more over 3 times more than probable to ROSC than those non-epinephrine administration. (Fig. 6)

Figure 6:

Wood plots of ROSC suggested Patients receiving epinephrine were more than over three times more likely to ROSC than those non-epinephrine assistants.

There was no evidence of publication bias every bit suggested by Egger examination (P = .746 > .05).

3.4 Cerebral performance category (CPC) 1 or 2

3 studies^{[10,twenty,23]} were included for pooling epinephrine administration effects on CPC ane or 2 with the sample sizes of 4380 for epinephrine and 4329 for not-epinephrine groups. Considering moderate heterogeneous (Iⁱⁱ = 40.v%) a fixed-furnishings model was performed and yielded a pooled RR of ane.fifteen (95% CI: 0.86, 1.54), and there was no pregnant departure between the two groups (P = .340). There was no evidence of publication bias every bit suggested by Egger exam (P = .440 > .05). (Fig. 7).

Figure 7:

Forest plots of CPC 1 or two in patients with epinephrine vs those without epinephrine administration for OHCA demonstrated there was no significant deviation between the 2 groups.

3.5 Infirmary admission

Studies^[10,20,23] assessed the relation between epinephrine administration and hospital access. The effect of epinephrine highly varied across studies (I² = 88.2%), information technology was not statistically valid (P = .0001) with a pooled RR of 2.07 (95% CI: 1.28, 3.35). (Fig. viii) Therefore, we performed a sensitivity analysis by excluding the written report^[23] that was out of the interval in Galbraith plot for heterogeneous (Fig. nine) and the degree of heterogeneous wasn't improved (I^two = 77.3%, P = .0001) with a pooled RR of 2.51 (95% CI: 1.67, 3.76). After excluding another study^[10] the degree of heterogeneous decreased intrinsically (I² = 31.ii%, P = .0001) with a pooled RR of 1.71 (95% CI: ane.31, ii.32).

Effigy eight:

Forest plots of hospital admission suggested that the effect of epinephrine highly varied beyond studies and information technology was not statistically valid with a pooled RR of ii.07.

Effigy 9:

The galbraith plot for heterogeneous was to find the sources of heterogeneity.

A sensitivity analysis was performed past excluding the study^[23] which specifically concerned with drug furnishings of adrenaline in patients with initial pulseless electrical activeness (PEA). The caste of heterogeneity did not improve the degree of heterogeneity (Q = 4.41, d.f. = 1, P = .04, I^two = 77%) and with a pooled RR of 2.98 (95% CI: 2.57, 3.22). Excluding another study^[10] in which avant-garde life support was provided by trial-trained paramedics were eligible for inclusion decreased substantially (Q = 1.45, d.f. = 1, P = .23, Iⁱⁱ = 31%).

We, to some extent, but included ii studies to analyze and the result wasn't statistical deviation. Besides, some factors might bear upon the results though there was no compelling testify, which included the patient's age, CPR implementer, initial cardiac rhythm and many more.

iv Discussion

In electric current systematic review and meta-assay of randomized trials investigating epinephrine for out of hospital cardiac abort, nosotros found that epinephrine was associated with a significantly college likelihood of ROSC (RR = 3.05, Iⁱⁱ = 23.1%, P = .0001) and survival to hospital belch (RR = ane.forty, I² = 36.3%, P = .008) compared with not-adrenaline assistants. Conversely, epinephrine did not increase CPC 1 or 2 (RR = 1.xv, I² = forty.5%, P = .340) and infirmary access (RR = 2.07, I² = 88.2%, P = .0001).

In previous meta-analyses, they considered that in that location were no significant difference in hospital belch.^[9,16,25] In dissimilarity, respect to electric current study patients who have a cardiac arrest out of hospital and who are given adrenaline (epinephrine) by emergency medical services have more favorable survival to hospital discharge than those not given adrenaline, what made this was ascribed to α-adrenergic receptors^[4–6] and which was like to a previous RCT^[10] with large patients. What's more, our effect size was more precise than the finding by Belletti et al^[9] because the pooling was based on RCT of included studies than Belletti, which was based on only 1 study. In improver, Nakahara et al conducted a retrospective cohort study comparing epinephrine vs. no epinephrine for patients with ventricular fibrillation, pulse-less electric activity, or asystole,^[26] which found higher overall survival with epinephrine (17.0% vs thirteen.four%) and was like to us. On the contrary, the potential adverse effects of epinephrine include decreased total forward cardiac output, increased myocardial oxygen consumption, myocardial dysfunction postresuscitation,^[5,27,28] and increased pulmonary shunting.^[29] Even 1 study demonstrated Survival decrease with epinephrine (survival 0.43 (0.27–0.066) for stupor-able, 0.30 (0.07–0.82) for nonshockable rhythms).^[thirty] Also, another study suggested that patients with initially stupor-able rhythm demonstrate worse outcomes if they receive epinephrine in terms of survival at 1 month.^[26]

Comparing with non-epinephrine group it was seemed that epinephrine had some amend influence on survival to hospital discharge. However, whether or not to use epinephrine regularly demand more further studies that assessed the rate of disabled survival and severely disabled survival.^[26] What is more, such post-resuscitation intendance equally hypothermia should exist put into considering.^[31,32]

Epinephrine for OHCA caused constriction of peripheral vessels, increasing coronary and cerebral perfusion force per unit area.^[6] Our findings support the consequence of adrenaline in increasing prehospital ROSC, which is like to a RCT Olasveengen et al,^[33] systematic reviews past Atiksawedparit et al^[25] and some other studies.^[34,35] As well, Koscik et al retrospectively evaluated approximately 700 patients, finding earlier provision of epinephrine improves ROSC, from 21.5% to 48.half-dozen% (OR 3.45).^[36] Considering including studies didn't study the starting fourth dimension of epinephrine in item and only i study^[24] compared high-dose epinephrine with low-dose epinephrine, in addition, the studies included might utilize different definitions of ROSC, therefore, attributable to the insufficiency of the data, we couldn't fix a subgroup to clarify further.

With respect to CPC 1 or 2, the result constitute at that place was no significant difference. We considered that epinephrine increased macroscopic cerebral blood flow, it, yet, impaired cerebral microvascular blood period, leading a potential to worsen encephalon injury.^[37] Beyond that, what resulted in this might be that brain was more sensitive to ischemia and recovered poorly.^[38]

In the case of epinephrine lone it might be non the almost appropriate pick, some researcher considered vasopressin made an influence on a improve survival for the patients with asystole, conversely, comparing with the combined-use of epinephrine epinephrine lone improved the survival to infirmary belch for patients with pulseless electrical action.^[39] Moreover, a combination regimen of epinephrine, vasopressin and steroids during in-hospital cardiac arrest was associated with meliorate neurologically intact survival to hospital discharge, compared to epinephrine alone.^[40] The written report design which was the first RCT to demonstrate that medication was associated with more preferable long-term outcomes in patients with cardiac arrest evaluated the relative utility of the agents used in addition to epinephrine, rather than epinephrine itself. Nevertheless, it was important to note that it was not conducted in patients OHCA.

Hospital admission meant access afterward out-of-hospital cardiac arrest, several studies^[25,41] that included ane published recently consider there was no meaning difference in the pool of hospital admission, attributing to reason that adrenaline was intrinsically a short interim cardiovascular stimulant, which has a limited one-half-life, and it might be less probable to have a significant effect on long term outcomes for this reason.^[42] However, we deemed the epinephrine improves the rate of hospital admission indeed and did non deny the significance of epinephrine.

There are numerous strengths in current report. We include all the relevant RCTs to analyze, which could adjust for some known and unknown confounders. 2 independent reviewers used divers search terms and strategies to reduce pick bias. In add-on, the number of included studies is pocket-size, information technology, still, is larger and more than pervasive than other systematic reviews.^[25]

Nonetheless, our meta-assay has some limitations. Considering the small number of included studies and the lack of some data subgroups could not be accomplished, which also led limited exploration of sources of heterogeneity for pooled effects. In addition, we did not puddle more results considering of the information were bereft, except for Hospital belch, ROSC, CPC i or 2, Hospital admission. Meanwhile, 90% of the sample size came from i RCT^[10] reported in 2018. The results might be skewed past this study, on the contrary, we did assess the stability of each result by irresolute the RR and considered the results were stable. Finally, we did not specifically address confounders such every bit differences/variation in witnessed abort and bystander cardiopulmonary resuscitation (CPR) frequency, showtime daze, frequency of pulseless electrical activity, following guideline revision, and quality/intensity of post-ROSC care.

v Decision

In conclusion, in this systematic review and meta-analysis involving studies, the use of epinephrine resulted in a significantly higher likelihood of survival to infirmary discharge and ROSC than the not-epinephrine administration, but, there was no significant betwixt grouping difference in the rate of a favorable neurologic outcome. In the future, there is a need for more loftier-quality RCTs to reassess or ostend this conclusion.

Author contributions

Methodology: Lu Huan.

Resources: Lu Huan, Fei Qin.

Software: Lu Huan.

Validation: Fei Qin.

Writing – original draft: Lu Huan, Fei Qin.

Writing – review & editing: Fei Qin, Yin Wu.

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Keywords:

cardiac abort; epinephrine; hospital belch; resuscitation; render of spontaneous circulation

Copyright © 2019 the Author(due south). Published past Wolters Kluwer Health, Inc.

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