Epinephrine, vasopressin and steroids for in-hospital cardiac arrest: the right cocktail therapy?
Year: 2014
Type: book-review
Abstract: Mentzelopoulos SD, Malachias S, Chamos C, Konstantopoulos D, Ntaidou T, Papastylianou A, Kolliantzaki I, Theodoridi M, Ischaki H, Makris D, Zakynthinos E, Zintzaras E, Sourlas S, Aloizos S, Zakynthinos SG: Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. JAMA 2013, 310: 270 – 279. Among patients with cardiac arrest, preliminary data have shown improved return of spontaneous circulation and survival to hospital discharge with the vasopressin-steroids-epinephrine (VSE) combination. Objective: To determine whether combined vasopressin-epinephrine during cardiopulmonary resuscitation (CPR) and corticosteroid supplementation during and after CPR improve survival to hospital discharge with a Cerebral Performance Category (CPC) score of 1 or 2 in vasopressor-requiring, in-hospital cardiac arrest. Design: Randomized, double-blind, placebo-controlled, parallel-group trial performed from 1 September 2008 to 1 October 2010. Setting: Three Greek tertiary care centers. Subjects: Consecutive in-hospital cardiac arrest patients requiring epinephrine and aged more than 18 years (n = 268). Intervention: Patients received either vasopressin (20 IU/CPR cycle) plus epinephrine (1 mg/CPR cycle; cycle duration approximately 3 minutes; VSE group, n = 130) or saline placebo plus epinephrine (1 mg/CPR cycle; cycle duration approximately 3 minutes; control group, n = 138) for the first 5 CPR cycles after randomization, followed by additional epinephrine if needed. During the first CPR cycle after randomization, patients in the VSE group received methylprednisolone (40 mg) and patients in the control group received saline placebo. Shock after resuscitation was treated with stress-dose hydrocortisone (300 mg daily for 7 days maximum and gradual taper; VSE group, n = 76) or saline placebo (control group, n = 73). Outcomes: Return of spontaneous circulation (ROSC) for 20 minutes or longer and survival to hospital discharge with a CPC score of 1 or 2. Follow-up was completed in all resuscitated patients. Patients in the VSE group versus patients in the control group had higher probability for ROSC for 20 minutes or longer (109/130 (83.9%) versus 91/138 (65.9%); odds ratio (OR), 2.98; 95% confidence interval (CI), 1.39 to 6.40; P = 0.005) and survival to hospital discharge with CPC score of 1 or 2 (18/130 (13.9%) versus 7/138 (5.1%); OR, 3.28; 95% CI, 1.17 to 9.20; P = 0.02). In the subset of subjects with post-resuscitation shock, subjects in the VSE group versus patients in the control group had higher probability for survival to hospital discharge with CPC scores of 1 or 2 (16/76 (21.1%) versus 6/73 (8.2%); OR, 3.74; 95% CI, 1.20 to 11.62; P = 0.02), improved hemodynamics and central venous oxygen saturation, and less organ dysfunction. Adverse event rates were similar in the two groups. Among patients with cardiac arrest requiring vasopressors, combined vasopressin-epinephrine and methylprednisolone during CPR and stress-dose hydrocortisone in postresuscitation shock resulted in improved survival to hospital discharge with favorable neurological status compared with epinephrine.
Source: Critical Care
DOI: 10.1186/cc13903
Institution: University of Pittsburgh
Language: English
Subfield: Emergency Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $4,190
OpenAlex ID: W2109479355