Vasopressors during cardiopulmonary resuscitation. A network meta-analysis of randomized trials

Alessandro Belletti, U Benedetto, A Putzu, EA Martino, G Biondi-Zoccai, GD Angelini, A Zangrillo, G Landoni

Research output: Contribution to journalArticle

Abstract

Objectives: Several randomized controlled trials have compared adrenaline (epinephrine) with alternative therapies in patients with cardiac arrest with conflicting results. Recent observational studies suggest that adrenaline might increase return of spontaneous circulation but worsen neurologic outcome. We systematically compared all the vasopressors tested in randomized controlled trials in adult cardiac arrest patients in order to identify the treatment associated with the highest rate of return of spontaneous circulation, survival, and good neurologic outcome. Design: Network meta-analysis. Patients: Adult patients undergoing cardiopulmonary resuscitation. Interventions: PubMed, Embase, BioMed Central, and the Cochrane Central register were searched (up to April 1, 2017). We included all the randomized controlled trials comparing a vasopressor with any other therapy. A network meta-analysis with a frequentist approach was performed to identify the treatment associated with the highest likelihood of survival. Measurements and Main Results: Twenty-eight studies randomizing 14,848 patients in 12 treatment groups were included. Only a combined treatment with adrenaline, vasopressin, and methylprednisolone was associated with increased likelihood of return of spontaneous circulation and survival with a good neurologic outcome compared with several other comparators, including adrenaline. Adrenaline alone was not associated with any significant difference in mortality and good neurologic outcome compared with any other comparator. Conclusions: In randomized controlled trials assessing vasopressors in adults with cardiac arrest, only a combination of adrenaline, vasopressin, and methylprednisolone was associated with improved survival with a good neurologic outcome compared with any other drug or placebo, particularly in in-hospital cardiac arrest. There was no significant randomized evidence to support neither discourage the use of adrenaline during cardiac arrest. Copyright © 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Original languageEnglish
Pages (from-to)e443-e451
JournalCritical Care Medicine
Volume46
Issue number5
DOIs
Publication statusPublished - 2018

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Cardiopulmonary Resuscitation
Epinephrine
Heart Arrest
Nervous System
Randomized Controlled Trials
Survival
Methylprednisolone
Vasopressins
Therapeutics
Network Meta-Analysis
Complementary Therapies
PubMed
Observational Studies
Placebos
Mortality
Health
Pharmaceutical Preparations

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Vasopressors during cardiopulmonary resuscitation. A network meta-analysis of randomized trials. / Belletti, Alessandro; Benedetto, U; Putzu, A; Martino, EA; Biondi-Zoccai, G; Angelini, GD; Zangrillo, A; Landoni, G.

In: Critical Care Medicine, Vol. 46, No. 5, 2018, p. e443-e451.

Research output: Contribution to journalArticle

Belletti A, Benedetto U, Putzu A, Martino EA, Biondi-Zoccai G, Angelini GD et al. Vasopressors during cardiopulmonary resuscitation. A network meta-analysis of randomized trials. Critical Care Medicine. 2018;46(5):e443-e451. https://doi.org/10.1097/CCM.0000000000003049
Belletti, Alessandro ; Benedetto, U ; Putzu, A ; Martino, EA ; Biondi-Zoccai, G ; Angelini, GD ; Zangrillo, A ; Landoni, G. / Vasopressors during cardiopulmonary resuscitation. A network meta-analysis of randomized trials. In: Critical Care Medicine. 2018 ; Vol. 46, No. 5. pp. e443-e451.
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abstract = "Objectives: Several randomized controlled trials have compared adrenaline (epinephrine) with alternative therapies in patients with cardiac arrest with conflicting results. Recent observational studies suggest that adrenaline might increase return of spontaneous circulation but worsen neurologic outcome. We systematically compared all the vasopressors tested in randomized controlled trials in adult cardiac arrest patients in order to identify the treatment associated with the highest rate of return of spontaneous circulation, survival, and good neurologic outcome. Design: Network meta-analysis. Patients: Adult patients undergoing cardiopulmonary resuscitation. Interventions: PubMed, Embase, BioMed Central, and the Cochrane Central register were searched (up to April 1, 2017). We included all the randomized controlled trials comparing a vasopressor with any other therapy. A network meta-analysis with a frequentist approach was performed to identify the treatment associated with the highest likelihood of survival. Measurements and Main Results: Twenty-eight studies randomizing 14,848 patients in 12 treatment groups were included. Only a combined treatment with adrenaline, vasopressin, and methylprednisolone was associated with increased likelihood of return of spontaneous circulation and survival with a good neurologic outcome compared with several other comparators, including adrenaline. Adrenaline alone was not associated with any significant difference in mortality and good neurologic outcome compared with any other comparator. Conclusions: In randomized controlled trials assessing vasopressors in adults with cardiac arrest, only a combination of adrenaline, vasopressin, and methylprednisolone was associated with improved survival with a good neurologic outcome compared with any other drug or placebo, particularly in in-hospital cardiac arrest. There was no significant randomized evidence to support neither discourage the use of adrenaline during cardiac arrest. Copyright {\circledC} 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.",
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AU - Angelini, GD

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AU - Landoni, G

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N2 - Objectives: Several randomized controlled trials have compared adrenaline (epinephrine) with alternative therapies in patients with cardiac arrest with conflicting results. Recent observational studies suggest that adrenaline might increase return of spontaneous circulation but worsen neurologic outcome. We systematically compared all the vasopressors tested in randomized controlled trials in adult cardiac arrest patients in order to identify the treatment associated with the highest rate of return of spontaneous circulation, survival, and good neurologic outcome. Design: Network meta-analysis. Patients: Adult patients undergoing cardiopulmonary resuscitation. Interventions: PubMed, Embase, BioMed Central, and the Cochrane Central register were searched (up to April 1, 2017). We included all the randomized controlled trials comparing a vasopressor with any other therapy. A network meta-analysis with a frequentist approach was performed to identify the treatment associated with the highest likelihood of survival. Measurements and Main Results: Twenty-eight studies randomizing 14,848 patients in 12 treatment groups were included. Only a combined treatment with adrenaline, vasopressin, and methylprednisolone was associated with increased likelihood of return of spontaneous circulation and survival with a good neurologic outcome compared with several other comparators, including adrenaline. Adrenaline alone was not associated with any significant difference in mortality and good neurologic outcome compared with any other comparator. Conclusions: In randomized controlled trials assessing vasopressors in adults with cardiac arrest, only a combination of adrenaline, vasopressin, and methylprednisolone was associated with improved survival with a good neurologic outcome compared with any other drug or placebo, particularly in in-hospital cardiac arrest. There was no significant randomized evidence to support neither discourage the use of adrenaline during cardiac arrest. Copyright © 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

AB - Objectives: Several randomized controlled trials have compared adrenaline (epinephrine) with alternative therapies in patients with cardiac arrest with conflicting results. Recent observational studies suggest that adrenaline might increase return of spontaneous circulation but worsen neurologic outcome. We systematically compared all the vasopressors tested in randomized controlled trials in adult cardiac arrest patients in order to identify the treatment associated with the highest rate of return of spontaneous circulation, survival, and good neurologic outcome. Design: Network meta-analysis. Patients: Adult patients undergoing cardiopulmonary resuscitation. Interventions: PubMed, Embase, BioMed Central, and the Cochrane Central register were searched (up to April 1, 2017). We included all the randomized controlled trials comparing a vasopressor with any other therapy. A network meta-analysis with a frequentist approach was performed to identify the treatment associated with the highest likelihood of survival. Measurements and Main Results: Twenty-eight studies randomizing 14,848 patients in 12 treatment groups were included. Only a combined treatment with adrenaline, vasopressin, and methylprednisolone was associated with increased likelihood of return of spontaneous circulation and survival with a good neurologic outcome compared with several other comparators, including adrenaline. Adrenaline alone was not associated with any significant difference in mortality and good neurologic outcome compared with any other comparator. Conclusions: In randomized controlled trials assessing vasopressors in adults with cardiac arrest, only a combination of adrenaline, vasopressin, and methylprednisolone was associated with improved survival with a good neurologic outcome compared with any other drug or placebo, particularly in in-hospital cardiac arrest. There was no significant randomized evidence to support neither discourage the use of adrenaline during cardiac arrest. Copyright © 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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