The Use of Norepinephrine vs Epinephrine in Post Cardiac Arrest Shock

The Use of Norepinephrine vs Epinephrine in Post Cardiac Arrest Shock

Pharmacy Friday Pearl – Pharmacy & Acute Care University

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Introduction

  • The effects of epinephrine on animal hemodynamics have been studied since the late 1800s with recent concern regarding deleterious complications with cerebral and myocardial oxygen supply.
  • Recently, norepinephrine has been considered post cardiac arrest to minimize complications associated with epinephrine.

Pharmacology of Epinephrine and Norepinephrine

Category Epinephrine Norepinephrine
Dose Weight-based: 0.01–1 mcg/kg/min
Non-weight-based: 1–80 mcg/min
Institutional infusion rates may vary
Weight-based: 0.05–1 mcg/kg/min (initiate at 0.05–0.15)
Non-weight-based: 5–80 mcg/min (initiate at 5–15)
Institutional infusion rates may vary
Pharmacokinetics Onset: Immediate
Distribution: 1–2 min to peak
Metabolism: hepatic
Elimination: urine (inactive metabolites)
Half-life: <5 min
Onset: Immediate
Distribution: 1–2 min to peak
Metabolism: hepatic
Elimination: urine (inactive metabolites)
Half-life: <5 min
Adverse Effects Tachyarrhythmias, myocardial ischemia, extravasation leading to necrosis
Mechanism of Action α agonist → Peripheral vasoconstriction → ↑ myocardial & cerebral blood flow
β agonist → ↑ heart rate & contractility → ↑ myocardial oxygen demand
Compatibility Refer to institutional policies for line compatibility and Y-site administration.

Clinical pearl: Norepinephrine may offer a hemodynamic advantage over epinephrine in certain post-arrest scenarios.

Overview of Key Evidence

Author/Year Design (n) Key Findings
Bougouin, 2022 Retrospective (N=766) Epinephrine group had higher all-cause hospital mortality (OR 2.6; 95% CI 1.4–4.7; P=0.002) and more CPC 3–5 at discharge.
Weiss, 2021 Retrospective (N=93) EPI group had more refractory hypotension, rearrest, or death in ED (50% vs 22.2%; P=0.008); adjusted odds of adverse events 3.94 times higher (P=0.013).
Mion, 2014 Case report (N=1) After recurrent VF with epinephrine, transition to norepinephrine led to ROSC and full recovery post ICU stay.
Kim, 2012 Retrospective (N=90) Survivors were more likely to have received norepinephrine (34.8% vs 22.6%); even more pronounced in prolonged arrest group (42.85% vs 25%).

Clinical Conclusions

  • It remains controversial whether epinephrine is the preferred vasopressor post-cardiac arrest.
  • Norepinephrine is a reasonable alternative post-arrest, particularly when adverse effects from epinephrine are of concern.

Full Reference List

  1. Micromedex [Electronic version]. Greenwood Village, CO: Truven Health Analytics. Accessed 2022, March 15. http://www.micromedexsolutions.com/
  2. Callaway C. Epinephrine for cardiac arrest. Current Opinion in Cardiology. 2013;28(1):36-42.
  3. Epinephrine [package insert] Lake Forest, IL: Hospira, Inc.; 2019.
  4. Kim et al. THE BENEFIT OF NOREPINEPHRINE INFUSION FOR HEMODYNAMIC SUPPORT FOLLOWING CARDIOPULMONARY ARREST AND RESUSCITATION. Critical Care Medicine. 2012;40(12):1-328.
  5. Mion G, et al. Cardiac arrest: should we consider norepinephrine instead of epinephrine? Am J Emerg Med. 2014;32(12):1560.e1-2. PMID: 24997106.
  6. Weiss A, et al. Comparison of Clinical Outcomes with Initial Norepinephrine or Epinephrine for Hemodynamic Support After Return of Spontaneous Circulation. Shock. 2021;56(6):988-993. PMID: 34172611.
  7. Bougouin W, et al. Epinephrine versus norepinephrine in cardiac arrest patients with post-resuscitation shock. Intensive Care Med. 2022;48(3):300-310. PMID: 35129643.

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