Mortality, morbidity & clinical outcome with different types of vasopressors in out of hospital cardiac arrest patients- a systematic review and meta-analysis

Abstract

Background & objective: Despite their continued use, the effectiveness and safety of vasopressors in post-cardiac arrest patients remain controversial. This study examined the efficacy of various vasopressors in cardiac arrest patients in terms of clinical, morbidity, and mortality outcomes.

Methods: A comprehensive literature search was performed using online databases (MeSH terms: MEDLINE (Ovid), CENTRAL (Cochrane Library), Embase (Ovid), CINAHL, Scopus, and Google Scholar) from 1997 to 2023 for relevant English language studies. The primary outcomes of interest for this study included short-term survival leading to death, return of spontaneous circulation (ROSC), survival to hospital discharge, neurological outcomes, survival to hospital admission, myocardial infarction, and incidence of arrhythmias.

Results: In this meta-analysis, 26 studies, including 16 RCTs and ten non-RCTs, were evaluated. The focus was on the efficacy of epinephrine, vasopressin, methylprednisolone, dopamine, and their combinations in medical emergencies. Epinephrine treatment was associated with better odds of survival to hospital discharge (OR = 1.52, 95%CI [1.20, 1.94]; p < 0.001) and achieving ROSC (OR = 3.60, 95% CI [3.45, 3.76], P < 0.00001)) over placebo but not in other outcomes of interest such as short-term survival/ death at 28-30 days, survival to hospital admission, or neurological function. In addition, our analysis indicates non-superiority of vasopressin or epinephrine vasopressin-plus-epinephrine therapy over epinephrine monotherapy except for survival to hospital admission where the combinatorial therapy was associated with better outcome (0.76, 95%CI [0.64, 0.92]; p = 0.004). Similarly, we noted the non-superiority of vasopressin-plus-methylprednisolone versus placebo. Finally, while higher odds of survival to hospital discharge (OR = 3.35, 95%CI [1.81, 6.2]; p < 0.001) and ROSC (OR = 2.87, 95%CI [1.97, 4.19]; p < 0.001) favoring placebo over VSE therapy were observed, the risk of lethal arrhythmia was not statistically significant. There was insufficient literature to assess the effects of dopamine versus other treatment modalities meta-analytically.

Conclusion: This meta-analysis indicated that only epinephrine yielded superior outcomes among vasopressors than placebo, albeit limited to survival to hospital discharge and ROSC. Additionally, we demonstrate the non-superiority of vasopressin over epinephrine, although vasopressin could not be compared to placebo due to the paucity of data. The addition of vasopressin to epinephrine treatment only improved survival to hospital admission.

Keywords: Cardiac arrest; Cardiopulmonary resuscitation; Ionotropic; ROSC; Return of spontaneous circulation; Vasopressors.

Fig. 1

PRISMA flow diagram

Fig. 2

Risk of bias assessment (graph & summary)

Fig. 3

Forest plot of comparison (epinephrine vs placebo): short-term survival/death within 30 days

Fig. 4

Forest plot of comparison (epinephrine vs placebo): achieving ROSC.

Fig. 5

Forest plot of comparison (epinephrine vs placebo): neurologic function

Fig. 6

Forest plot of comparison (epinephrine vs placebo): survival to hospital admission

Fig. 7

Forest plot of comparison (epinephrine vs placebo): survival to hospital discharge

Fig. 8

Forest plot of comparison: epinephrine vs vasopressin

Fig. 9

Forest plot comparison: epinephrine plus vasopressin vs. epinephrine

Fig. 10

Forest plot comparison: vasopressin + methylprednisolone vs. epinephrine

Fig. 11

Forest plot of comparison: vasopressin, steroids, and epinephrine (vse) vs. epinephrine alone.