Norepinephrine vs. Epinephrine for Post-Arrest Shock

Written by Catherine Burger

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This meta-analysis shows decreased episodes of repeat cardiac arrest when post-arrest shock was treated with norepinephrine vs. epinephrine, but there were no differences in survival or discharge with good neurological outcome.

Norepinephrine edges out epi in post-arrest shock
This systematic review and meta-analysis compared the efficacy of epinephrine (EPI) and norepinephrine (NE) in treating post-resuscitative shock in adult patients who achieve return of spontaneous circulation after cardiac arrest, with a focus on frequency of recurrent arrest. Six studies were included in data analysis: 1 randomized control trial and 5 retrospective observational studies. A total of 3,458 patients with post-resuscitative shock were included, with 1,833 (53%) treated with NE and 1625 (47%) treated with EPI. Many important patient characteristics were missing from the data, such as duration of cardiopulmonary resuscitation, initial cardiac rhythm, witnessed vs. unwitnessed arrest, treatment with targeted temperature management, and doses of NE and EPI given.

A total of 703 (20%) patients experienced recurrent arrest, with 287 (41%) from the NE treatment group and 416 (59%) from the EPI treatment group. Treatment with NE was associated with lower odds of recurrent arrest (OR 0.47, 95%CI 0.24–0.92, P= 0.03). From the available data, 494 (14%) of patients survived to hospital discharge. A larger proportion of the NE treatment group survived to discharge, but this was not statistically significant and was confounded by more patients presenting with a shockable rhythm in the NE group. Authors also note no statistically significant difference in rates of hospital discharge with favorable neurological outcome between the two groups.

How will this change my practice?
Even though the benefits in this study were not mortality-centered, these results further affirm norepinephrine as my go-to pressor for adults with shock, including the post-arrest setting.

Source
Norepinephrine versus epinephrine after cardiac arrest: A systematic review and meta-analysis. Am J Emerg Med. 2025 Sep;95:107-114. doi: 10.1016/j.ajem.2025.05.038. Epub 2025 May 22. PMID: 40440817.