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Vasopressor Use During Cardiac Arrest

Question Type:
Intervention
Full Question:
Among infants and children in cardiac arrest (P), does does the use of no vasopressor (epinephrine, vasopressin, combination of
vasopressors) (I), compared with compared with any use of vasopressors (C), change survival to 180 days with good neurological outcome, survival to hospital discharge, ROSC (O)?
Consensus on Science:
For infants and children in cardiac arrest (P), there are no studies that directly inform whether the use of no vasopressors (epinephrine, combination of vasopressors) (I), compared with the use of any vasopressors (C), change survival to 180 days with good neurologic outcome, survival to hospital discharge, or ROSC (O). For the critical outcome of survival with good neurologic outcome, we identified very-low-quality evidence (downgraded for indirectness, imprecision, inconsistency, and high risk of bias) from 2 pediatric out-of-hospital observational studies including 74 patients suggesting that the use of vasopressors versus no vasopressors has an uncertain benefit(Dieckmann 1995, 901-913; Enright 2012, 336-339) (Dieckmann: RR, 2.0; 95% CI, 0.50–7.98). For the important outcome of survival to hospital discharge, we identified very-low-quality evidence (downgraded for indirectness, imprecision, inconsistency, and high risk of bias) from 2 pediatric out-of-hospital observational studies including 74 patients suggesting that the use of vasopressors versus no vasopressors has an uncertain benefit(Dieckmann 1995, 901-913; Enright 2012, 336-339) (Dieckmann: RR, 1.67; 95% CI, 0.82–3.41). For the important outcome of ROSC, we identified very-low-quality evidence (downgraded for indirectness, imprecision, inconsistency, and high risk of bias) from 2 pediatric out-of-hospital observational studies including 74 patients suggesting that the use of vasopressors versus no vasopressors has an uncertain benefit(Dieckmann 1995, 901-913; Enright 2012, 336-339) (Dieckmann: RR, 0.95; 95% CI, 0.80–1.14). For all critical and important outcomes, we reviewed and considered a single underpowered adult OHCA RCT that provided very-low-quality evidence (downgraded for very serious indirectness, imprecision, and risk of bias) comparing standard-dose epinephrine to placebo.(Jacobs 2011, 1138-1143) For the critical outcome of good neurologic outcome and important outcome of survival to discharge, there was uncertain benefit or harm of standard-dose epinephrine compared with placebo. For the important outcomes of survival to hospital admission and ROSC, there was possible benefit of standard-dose epinephrine compared with placebo. (See also adult PICO question 788 in “Part 4: Advanced Life Support.”)
Treatment Recommendation:
The confidence in effect estimates is so low that the panel decided a recommendation was too speculative. Values, Preferences, and Task Force Insights In considering making a recommendation, owing to the paucity of pediatric evidence of benefit or harm, the task force placed value on the short-term outcomes of ROSC and survival to hospital admission over any uncertainty of the beneficial or harmful effect on long-term survival and neurologic outcome. It is reasonable for providers to use standard-dose epinephrine for pediatric cardiac arrest management.
CoSTR Attachments:
GDT - recommendation revision_21Jan2015.docx    
Vasopressor evidence tables_07Jan2015vn.docx    

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