In this episode, I’ll discuss an article about the effects of epinephrine infusion on survival in critically ill patients.
Article
Lead author: Alessandro Belletti
Published in Critical Care Medicine February 2020
Background
While epinephrine is commonly used to provide both inotropic and vasopressor support to critically ill patients, it is usually not considered first line in part due to an association with worse patient outcomes.
The authors of this study performed a systematic review and meta-analysis of randomized controlled trials to better describe the effect of epinephrine administration on outcome of critically ill patients.
Methods
The authors included randomized trials involving administration of epinephrine as IV continuous infusion in patients admitted to an ICU or undergoing major surgery. Studies that examined bolus doses such as during CPR or as one-time doses were excluded from the review.
Clinically meaningful outcomes were examined with the primary outcome being mortality at the longest follow-up available.
Results
A total of 12 studies representing 1,227 patients were included in the meta-analysis. Most of the included trials were performed in patients with septic shock, and the most frequent comparator was a combination of norepinephrine plus dobutamine.
The authors found no difference in all-cause mortality at the longest follow-up available in the epinephrine group vs the control group. For this outcome the I2 value was 0%, indicating no observed heterogeneity.
The authors also found no differences in the need for renal replacement therapy, occurrence rate of myocardial ischemia, occurrence rate of arrhythmias, and length of ICU stay between the epinephrine and control group.
Conclusion
The authors concluded:
Current randomized evidence showed that continuous IV administration of epinephrine as inotropic/vasopressor agent is not associated with a worse outcome in critically ill patients.
Discussion
It is important to note that the dose of epinephrine used in most of the trials in this analysis was in the range of 0.1–0.3 µg/kg/min. Previous studies that have suggested an increased risk of mortality with epinephrine identified doses exceeding 0.5mcg/kg/min as being problematic. While this study does not disprove those results it does strongly suggest that epinephrine at lower doses is not associated with a worse outcome than if other vasopressors are used.
A slightly elevated lactate was found in the epinephrine group, and this is an expected finding based on the known tendency of epinephrine to raise serum lactate.
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