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Epinephrine Versus Vasopressin in Combination With Epinephrine

Question Type:
Intervention
Full Question:
Among adults who are in cardiac arrest in any setting (P), does does use of both vasopressin and epinephrine  (I), compared with compared with using epinephrine alone  (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 the critical outcome of survival to hospital discharge with CPC of 1 or 2, we found very-low-quality evidence (downgraded for very serious bias and serious imprecision) from 3 RCTs(Wenzel 2004, 105; Gueugniaud 2008, 21; Ong 2012, 953) (n=2402) comparing SDE with vasopressin and epinephrine combination therapy that showed no superiority with vasopressin and epinephrine combination (RR, 1.32; 95% CI, 0.88–1.98 and ARR, 0.5%; 95% CI, −0.2% to 1.3%, which translates to 5 more patients/1000 [95% CI, 2 fewer patients/1000 to 13 more/1000] surviving to hospital discharge with a CPC of 1 or 2 with vasopressin in combination with epinephrine).For the critical outcome of survival to hospital discharge, we found very-low-quality evidence (downgraded for very serious bias and serious imprecision) from 5 RCTs(Lindner 1997, 535; Wenzel 2004, 105; Gueugniaud 2008, 21; Ducros 2011, 453; Ong 2012, 953) (n=2438) comparing SDE to vasopressin and epinephrine combination therapy that did not show superiority with vasopressin and epinephrine combination therapy in survival to discharge (RR, 1.12; 95% CI, 0.84–1.49; P=0.45 and ARR, −0.17%; 95% CI, −1.3 to 1, which translates to 2 fewer patients/1000 [95% CI, 13 fewer patients/1000 to 10 more/1000] surviving to hospital discharge with vasopressin in combination with epinephrine). For the important outcome of survival to admission, we found moderate-quality evidence (downgraded for serious bias) from 5 RCTs(Lindner 1997, 535; Wenzel 2004, 105; Gueugniaud 2008, 21; Ducros 2011, 453; Ong 2012, 953) (n=2438) showing no significant differences in survival to hospital admission with vasopressin and epinephrine combination therapy (RR, 0.88; 95% CI, 0.73–1.06; P=0.17).For the important outcome of ROSC, we found moderate-quality evidence (downgraded for serious bias) from 6 RCTs(Lindner 1997, 535; Wenzel 2004, 105; Callaway 2006, 1316; Gueugniaud 2008, 21; Ducros 2011, 453; Ong 2012, 953) showing no ROSC advantage with vasopressin and epinephrine combination therapy (RR, 0.96; 95% CI, 0.89–1.04; P=0.31).
Treatment Recommendation:
We suggest against adding vasopressin to SDE during cardiac arrest (weak recommendation, moderate-quality evidence).
Values, Preferences, and Task Force Insights:
In making this recommendation, we preferred to avoid the additional expense and implementation issues required to add a drug (vasopressin) that has no evidence of additional benefit for patients.
CoSTR Attachments:
C2015_Worksheet_ALS_Vasopressors in cardiac arrest Jan 2 2015_n.docx    
Epi vs. Epi Vaso Combo_n.docx    
PRISMA Checklist for Vasopressor SR and MA_n.docx    
work sheet on vaso Feb 6 2015_n.docx    

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