In this episode, I’ll discuss whether epinephrine infusions are associated with worse mortality.
Many clinicians will remember the old phrase “leave ’em dead with Levophed” – a suggestion that norepinephrine was to be used as a last-line vasopressor. Guidelines for sepsis and septic shock have recommended norepinephrine as first-line therapy for over a decade however, and epinephrine is now regarded as a third-line vasopressor behind vasopressin and norepinephrine.
To examine whether the use of epinephrine continuous infusion as a vasopressor was associated with increased mortality, researchers conducted a systematic review and meta-analysis of randomized controlled trials. The goal of this review was to investigate the effect of epinephrine administration on the outcome of critically ill patients.
12 studies representing over 1000 patients were included in the final analysis.
Most trials were of patients with septic shock, and epinephrine was most frequently compared with norepinephrine plus dobutamine.
The authors used the longest follow up available for each study, and did not find a difference in all-cause mortality between groups.
Furthermore, the authors did not identify a difference between groups when they looked at secondary outcomes such as need for renal replacement therapy, rates of myocardial ischemia, arrhythmias, and length of ICU stay.
Although the review did not find that epinephrine was associated with worse outcomes, the authors were not satisfied with the small number of patients in the available evidence, and they suggest that prospective studies should be done to further investigate differences between vasopressors.
Because epinephrine stimulates both alpha and beta receptors, it is usually selected when both an increase in cardiac output and mean arterial pressure are desired. The authors wish to reassure intensivists and anesthesiologists that based on their review, epinephrine is a safe alternative to norepinephrine.
The review did determine that epinephrine is associated with increased lactate levels, but this increase is harmless and transient and does not represent worsening perfusion.
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So the study did not support the bias of the authors, as evidenced by the title “Are epinephrine infusions associated with worse mortality”. Rather than some neutral title, are epinephrine infusions better, the same or worse than norepi plus dobutamine?
And when you don’t get the answer you want, enlarge the study until you get the cases that support your bias. Good work.