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  • Dr. Bertha Wu

JOURNAL CLUB - MAY 2022

Updated: Nov 3, 2023

Journal Club Podcast May 2022

Dr Bertha Wu Dr David McCreary Prof Peter Cameron



WELCOME TO THE MAY JOURNAL CLUB PODCAST. WE ARE JOINED BY PROFESSOR PETER CAMERON, ACADEMIC DIRECTOR FOR THE ALFRED EMERGENCY AND TRAUMA CENTRE, AND EMERGENCY PHYSICIAN DR DAVID MCCREARY.


In May's journal club, we covered papers considering vasopressor choice in post OHCA patients in shock, trainee-supervisor power and trust dynamics in context of WBAs, front of neck access techniques, as well as effectiveness of sotrovimab in treating patients with risk of progressing to severe COVID-19.


PAPER 1: EPINEPHRINE VERSUS NOREPINEPHRINE IN CARDIAC ARREST PATIENTS WITH POST-RESUSCITATION SHOCK

READ IT HERE

CLINICAL QUESTION:

Does epinephrine cause more harm than norepinephrine in treating cardiac arrest patients with post resuscitation shock?

WHY IS THIS TOPIC IMPORTANT:

  • Poor survival after out of hospital cardiac arrest (10%)

  • Only 1/3 admitted to hospital alive, of which, half to 2/3 die during ICU admission due to neurological injury or haemodynamic failure (refractory shock or recurrent cardiac arrest)

  • Theoretical risk of harm for adrenaline use: increased cardiac contractility + heart rate à increased myocardial O2 demand à theoretically could exacerbate myocardial damage

  • Few head-to-head studies comparing vasopressor use in OHCA. There had been some studies comparing epinephrine and norepinephrine in shock due to sepsis. A recent RCT looked at mortality between the epinephrine and norepinephrine arms in cardiogenic shock post MI, but the study was underpowered.

  • No study has compared epinephrine and norepinephrine use in patients with post resuscitation shock

DESIGN

Registry-based, multicentre observational study

Population


Inclusion:

  • Data of patients included in study was pulled from the Sudden Death Expertise Centre Registry in the Paris metropolitan area

  • Patients admitted to five university hospitals alive and managed for post-resuscitation shock after OHCA from 2011-2018 were included

  • Post resuscitation shock was defined as a need for vasopressors for more than 6hrs despite adequate fluid loading. The target mean was 65mmHg.

Exclusion:

  • Obvious extra cardiac cause of cardiac arrest eg trauma, drowning, drug overdose, electrocution, asphyxia due to external cause

  • Refractory cardiac arrest without sustainable ROSC

  • Refractory shock requiring extracorporeal membrane oxygenation

  • Absence of continuous intravenous treatment with epinephrine or norepinephrine

Pts who had continuous intravenous treatment with both epinephrine and norepinephrine were initially excluded, but later on included in additional analysis.


INTERVENTION

Epinephrine infusion during ICU stay


COMPARISON

Norepinephrine infusion during ICU stay


OUTCOMES

Primary outcome:

  • All-cause hospital mortality during hospital stay

Secondary outcomes:

  • Cardiovascular hospital mortality (recurrent cardiac arrest or refractory haemodynamic shock)

  • Unfavorable neurological outcome (Cerebral Performance Category 3-5)

FINDINGS

766 patients from 5 hospitals were included in study à 285 (37%)