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Epinephrine Versus Placebo

Question Type:
Intervention
Full Question:
Among adults who are in cardiac arrest in any setting  (P), does does the use of epinephrine  (I), compared with compared with placebo or not using epinephrine  (C), change Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC (O)?
Consensus on Science:
For all 4 long-term and short-term outcomes, we found 1 underpowered RCT that provided low-quality evidence (downgraded for selection and ascertainment bias) comparing SDE with placebo(Jacobs 2011, 1138) in 534 subjects. For the critical outcome of survival to discharge, there was uncertain benefit or harm of SDE over placebo (RR, 2.12; 95% CI, 0.75–6.02; P=0.16; absolute risk reduction [ARR], 2.14%; 95% CI, −0.91% to 5.38%, or 21 more patients/1000 survived with epinephrine [95% CI, 9 fewer patients/1000 to 54 more patients/1000 survived with epinephrine]). For the critical outcome of survival to discharge with good neurologic outcome (defined as CPC of 1–2), there was uncertain benefit or harm of SDE over placebo (RR, 1.73; 95% CI, 0.59–5.11; P=0.32; ARR, 1.4%; 95% CI, −1.5% to 4.5%, which translates to 14 more patients/1000 survived with a CPC score of 1 or 2 with epinephrine [95% CI, 15 fewer patients/1000 to 45 more patients/1000 survived with a CPC score of 1 or 2 when given epinephrine]). For the important outcome of survival to admission, patients who received SDE had higher rates of survival to admission (RR, 1.95; 95% CI, 1.34–2.84; P=0.0004; ARR, 12%; 95% CI, 5.7%–18.9%, which translates to 124 more patients/1000 survived to admission with epinephrine [95% CI, 57–189 more patients/1000 survived to admission]). For the important outcome of ROSC in the prehospital setting, 151 more patients/1000 achieved ROSC with epinephrine (95% CI, 90–212 more patients/1000 achieved ROSC with epinephrine) when compared with those who received placebo (RR, 2.80; 95% CI, 1.78–4.41; P
Treatment Recommendation:
We suggest SDE be administered to patients in cardiac arrest (weak recommendation, very-low-quality evidence).Values, Preferences, and Task Force Insights:We make this statement after considering the observed benefit in short-term outcomes (ROSC and admission to hospital) and our uncertainty about the benefit or harm on survival to discharge and neurologic outcome given the limitations of the observational studies. Our statement is not intended to change current practice until there are high-quality data on long-term outcomes. We have considered 1 mg to be the standard dose of epinephrine.
CoSTR Attachments:
C2015_Worksheet_ALS_Vasopressors in cardiac arrest Jan 2 2015_n.docx    
Epi vs. Placebo_n.docx    
PRISMA Checklist for Vasopressor SR and MA_n.doc    
work sheet on vaso Feb 6 2015_n.docx    

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