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Effect of Continuous Epinephrine Infusion on Survival in Critically Ill Patients. A Meta-Analysis of Randomized Trials

Belletti, Alessandro MD1; Nagy, Adam MD1,2; Sartorelli, Marianna MD1; Mucchetti, Marta MD1; Putzu, Alessandro MD3; Sartini, Chiara MD1; Morselli, Federica MD1; De Domenico, Pierfrancesco MD1; Zangrillo, Alberto MD1,4; Landoni, Giovanni MD1,4; Lembo, Rosalba MSc1

doi: 10.1097/CCM.0000000000004127
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Objectives: Epinephrine is frequently used as an inotropic and vasopressor agent in critically ill patients requiring hemodynamic support. Data from observational trials suggested that epinephrine use is associated with a worse outcome as compared with other adrenergic and nonadrenergic vasoactive drugs. We performed a systematic review and meta-analysis of randomized controlled trials to investigate the effect of epinephrine administration on outcome of critically ill patients.

Data Sources: PubMed, EMBASE, and Cochrane central register were searched by two independent investigators up to March 2019.

Study Selection: Inclusion criteria were: administration of epinephrine as IV continuous infusion, patients admitted to an ICU or undergoing major surgery, and randomized controlled trials. Studies on epinephrine administration as bolus (e.g., during cardiopulmonary resuscitation), were excluded. The primary outcome was mortality at the longest follow-up available.

Data Extraction: Two independent investigators examined and extracted data from eligible trials.

Data Synthesis: A total of 5,249 studies were assessed, with a total of 12 studies (1,227 patients) finally included in the meta-analysis. The majority of the trials were performed in the setting of septic shock, and the most frequent comparator was a combination of norepinephrine plus dobutamine. We found no difference in all-cause mortality at the longest follow-up available (197/579 [34.0%] in the epinephrine group vs 219/648 [33.8%] in the control group; risk ratio = 0.95; 95% CI, 0.82–1.10; p = 0.49; I2 = 0%). No differences in the need for renal replacement therapy, occurrence rate of myocardial ischemia, occurrence rate of arrhythmias, and length of ICU stay were observed.

Conclusions: 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.

1Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.

2Károly Rácz School of PhD Studies, Semmelweis University, Budapest, Hungary.

3Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospital, Geneva, Switzerland.

4Vita-Salute San Raffaele University, Milan, Italy.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

The authors have disclosed that they do not have any potential conflicts of interest.

This trial was performed at the IRCCS San Raffaele Scientific Institute, Milan, Italy.

For information regarding this article, E-mail: mucchetti.marta@hsr.it

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