The Use of Norepinephrine vs Epinephrine in Post Cardiac Arrest Shock
Pharmacy Friday Pearl – Pharmacy & Acute Care University
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
- Micromedex [Electronic version]. Greenwood Village, CO: Truven Health Analytics. Accessed 2022, March 15. http://www.micromedexsolutions.com/
- Callaway C. Epinephrine for cardiac arrest. Current Opinion in Cardiology. 2013;28(1):36-42.
- Epinephrine [package insert] Lake Forest, IL: Hospira, Inc.; 2019.
- Kim et al. THE BENEFIT OF NOREPINEPHRINE INFUSION FOR HEMODYNAMIC SUPPORT FOLLOWING CARDIOPULMONARY ARREST AND RESUSCITATION. Critical Care Medicine. 2012;40(12):1-328.
- 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.
- 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.
- 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.