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Epinephrine Versus Vasopressin

Question Type:
Intervention
Full Question:
Among adults who are in cardiac arrest in any setting (P), does does use of epinephrine  (I), compared with compared with vasopressin  (C), change survival to 30 days with good neurological outcome, survival to 30 days, survival to hospital discharge with good neurological outcome, survival to hospital discharge, ROSC (O)?
Consensus on Science:
A single RCT(Mukoyama 2009, 755) (n=336) of low quality (downgraded for high risk of bias) compared multiple doses of SDE with multiple doses of standard-dose vasopressin in the ED after OHCA. Much of the methodology is unclear, and there was 37% postrandomization exclusion. The primary outcome measure was a CPC score of 1 or 2; however, neither the sample size estimate nor power calculation were included in the article.
For the critical outcome of survival to discharge with favorable neurologic outcome (CPC 1 or 2), there was no advantage with vasopressin (RR, 0.68; 95% CI, 0.25–1.82; P=0.44 or ARR, −1.6; 95% CI, −6 to 2.4, which translates to 16 fewer patients/1000 surviving with CPC 1 or 2 with vasopressin [95% CI, 60 fewer patients/1000 to 24 more patients/1000 survive with CPC 1 or 2]).
For the critical outcome of survival to discharge, RR was 0.68 (95% CI, 0.25–1.82; P=0.44 or ARR, 1.8%; 95% CI, −3.1 to 6.7, which translates to 18 more patients/1000 surviving to discharge with vasopressin [95% CI, 31 fewer patients/1000 surviving to discharge with vasopressin to 67 more patients/1000 surviving to discharge]).
For the important outcome of ROSC, there was no observed advantage with vasopressin (RR, 0.93; 95% CI, 0.66–1.31; P=0.67).
Treatment Recommendation:
We suggest vasopressin should not be used instead of epinephrine in cardiac arrest (weak recommendation, low-quality evidence).
We suggest that those settings already using vasopressin instead of epinephrine can continue to do so (weak recommendation, low-quality evidence).

Values, Preferences, and Task Force Insights
The recommendation considers the fact that vasopressin is already used in some settings, and the available data do not indicate any reason to stop using vasopressin if current treatment protocols already include vasopressin instead of epinephrine. Conversely, there is also no evidence to indicate that settings that use epinephrine should switch to using vasopressin.
CoSTR Attachments:
C2015_Worksheet_ALS_Vasopressors in cardiac arrest Jan 2 2015_n.docx    
Epi vs. Vasopressin_n.docx    
PRISMA Checklist for Vasopressor SR and MA_n.docx    
work sheet on vaso Feb 6 2015_n.docx    

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