The impact of vasopressor choice in patients with hypotension after cardiac arrest: a systematic review.

Abstract

To conduct a systematic review to evaluate the effects of vasopressor choice in adults following cardiac arrest. We searched 12 databases until 2nd May 2025 to identify studies that evaluated the clinical effectiveness of vasopressor choice in adults with hypotension following return of spontaneous circulation. Our outcomes of interest included survival and survival with favourable neurologic function. We assessed the risks of bias using the Cochrane Risk of Bias tool version 2 for randomised trials and the Risk of Bias in Non-randomised Studies - of Interventions tool for non-randomised studies. We evaluated the certainty of evidence using GRADE. We included eight studies (one RCT; seven non-randomised studies), which evaluated four comparisons, namely noradrenaline versus adrenaline (six studies), noradrenaline versus dopamine (one study), noradrenaline versus noradrenaline and dopamine (one study), and dopamine versus noradrenaline and adrenaline (one study). Study heterogeneity precluded meta-analysis. The single RCT found no evidence of difference in outcomes between noradrenaline and adrenaline. Results from other studies comparing noradrenaline and adrenaline were inconsistent. Some studies found no difference in outcomes, while others suggested an association between adrenaline use and worse outcomes. Across all studies, risk of bias was assessed as moderate or high, and evidence certainty for all comparisons and outcomes was assessed as very low. Existing evidence does not support the use of any specific vasopressor to treat hypotension following cardiac arrest and return of spontaneous circulation. There is a need for randomised controlled trials to identify the optimum strategy for blood pressure management following cardiac arrest and return of spontaneous circulation. PROSPERO CRD42024549394, https://www.crd.york.ac.uk/PROSPERO/view/CRD42024549394.