Comparative Efficacy and Safety of Intravenous Vasopressors in Pre-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis.

BACKGROUND

The effectiveness of vasopressors in out-of-hospital cardiac arrest (OHCA) remains unclear, despite their widespread use.

OBJECTIVES

This meta-analysis investigates the impact of different intravenous (IV) vasopressors on survival rates and neurological function in OHCA patients.

METHODS

A comprehensive search was conducted using PubMed, Medline, Embase, and Google Scholar for studies comparing vasopressor efficacy. The analysis included 30 studies with 949,511 OHCA patients. Data on the return of spontaneous circulation (ROSC), survival to hospital admission (SHA), survival to hospital discharge (SHD), 1-month survival, and neurological outcomes were pooled using a random-effects model. The overall effect size was calculated using odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

IV epinephrine improved prehospital ROSC (OR: 2.92, p = 0.0006) and SHA (OR: 1.57, p = 0.01) but did not affect SHD (OR: 0.99, p = 0.96) or 1-month survival (OR: 1.10, p = 0.59). Fewer patients treated with epinephrine achieved favorable neurological outcomes (OR: 0.70, p = 0.005). High-dose epinephrine (HDE) improved ROSC (OR: 1.19, p = 0.003) and SHA (OR: 1.20, p = 0.04) over standard-dose epinephrine (SDE) but not SHD or neurological outcomes. Vasopressin showed moderate benefits over epinephrine for SHA (OR: 0.71, p = 0.03), but epinephrine combined with vasopressin or norepinephrine offered no added benefits.

CONCLUSION

Epinephrine increases ROSC and SHA in OHCA patients but may worsen neurological outcomes. HDE improves ROSC and SHA over SDE but does not enhance SHD or neurological outcomes. Vasopressin offers moderate benefits, but combinations with other vasopressors do not improve outcomes.