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Comparative Study
. 2024 May:198:110201.
doi: 10.1016/j.resuscitation.2024.110201. Epub 2024 Apr 4.

A retrospective, multi-agency 'target trial emulation' for the comparison of post-resuscitation epinephrine to norepinephrine

Tanner Smida  1 , Remle P Crowe  2 , P S Martin  3 , James F Scheidler  3 , Bradley S Price  4 , James M Bardes  5
Affiliations
Comparative Study

A retrospective, multi-agency 'target trial emulation' for the comparison of post-resuscitation epinephrine to norepinephrine

Tanner Smida et al. Resuscitation. 2024 May.

Abstract

Introduction: Epinephrine and norepinephrine are the two most commonly used prehospital vasopressors in the United States. Prior studies have suggested that use of a post-ROSC epinephrine infusion may be associated with increased rearrest and mortality in comparison to use of norepinephrine. We used target trial emulation methodology to compare the rates of rearrest and mortality between the groups of OHCA patients receiving these vasopressors in the prehospital setting.

Methods: Adult (18-80 years of age) non-traumatic OHCA patients in the 2018-2022 ESO Data Collaborative datasets with a documented post-ROSC norepinephrine or epinephrine infusion were included in this study. Logistic regression modeling was used to evaluate the association between vasopressor agent and outcome using two sets of covariables. The first set of covariables included standard Utstein factors, the dispatch to ROSC interval, the ROSC to vasopressor interval, and the follow-up interval. The second set added prehospital systolic blood pressure and SpO2 values. Kaplan-Meier time-to-event analysis was also conducted and the vasopressor groups were compared using a multivariable Cox regression model.

Results: Overall, 1,893 patients treated by 309 EMS agencies were eligible for analysis. 1,010 (53.4%) received an epinephrine infusion and 883 (46.7%) received a norepinephrine infusion as their initial vasopressor. Adjusted analyses did not discover an association between vasopressor agent and rearrest (aOR: 0.93 [0.72, 1.21]) or mortality (aOR: 1.00 [0.59, 1.69]).

Conclusions: In this multi-agency target trial emulation, the use of a post-resuscitation epinephrine infusion was not associated with increased odds of rearrest in comparison to the use of a norepinephrine infusion.

Keywords: Adrenaline; Epinephrine; Noradrenaline; Norepinephrine; Post-ROSC; Rearrest.

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Conflict of interest statement

Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: ‘RPC is an employee of ESO. The aims of this investigation were reviewed by an independent committee before access to the data was granted. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the results reported in this paper.’.

Figures

Figure 1:
Figure 1:. CONSORT diagram.
This figure displays our sample derivation strategy from the ESO annual datasets.
Figure 2:
Figure 2:. Time From Vasopressor Administration to Rearrest, Stratified by Vasopressor Agent
A Kaplan-Meier time-to-event analysis was performed examining the time from vasopressor administration to the time of the first rearrest event. The difference between the norepinephrine group (blue) and the epinephrine group (red) was found to be non-significant in a multivariable Cox regression model (p=0.95)
See this image and copyright information in PMC

References

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