Utility of vasopressin and steroids in cardiac arrest

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Mentzelopoulous SD, et al. "Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: A randomized clinical trial". JAMA. 2013. 310(3):270-279.
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Clinical Question

In patients that suffer an in-hospital cardiac arrest, does the addition of vasopressin and corticosteroids to epinephrine improve clinical outcomes?

Bottom Line

Yes, the addition of vasopressin and steroid therapy during cardiac arrest can improve neurological outcomes and acheiving ROSC.

Major Points

Guidelines

None at this time.

Design

  • Multicenter, double-blind, placebo-controlled, parallel group trial
  • N= 268
    • Vasopressin-steroids-epinephrine (VSE)(n=130)
    • Epinephrine and placebos (n=138)
  • Setting: 3 Tertiary Care Centers in Greece
  • Enrollment: 2008-2010
  • Mean follow-up: 60 days
  • Analysis: On-Treatment
  • Primary outcomes: ROSC for >20 minutes, 60 day neurologically favorable survival (Cerebral Performance Category (CPC) score 1-2)

Population

Inclusion Criteria

  • In-hospital vasopressor-requiring cardiac arrest

Exclusion Criteria

  • Age <18
  • Terminal illness with life expectancy < 6 weeks
  • DNR status
  • Arrest due to exanguination
  • Arrest before hospitalization
  • Treatment with IV steroids before arrest

Baseline Characteristics

  • Mean age: 63 years in both arms
  • Mean BMI 25 in both arms

Characteristics below reported as (Total%,VRE%,Control%)

  • Male (68, 73, 64), not statistically different
  • Groups did not differ significantly in select cardiac and noncardiac comorbidities except cardiac conduction disturbances
    • VRE vs. Control 12%, 4% respectively p=0.03
  • Groups did not differ significantly in primary cause of hospitalization
    • Cardiac (28, 30, 26)
    • Respiratory (24, 20, 28)
    • Digestive (25, 17, 25)
    • Neurological (10, 12, 8)
    • Trauma (10, 10, 9)
    • Malignancy (8, 8, 9)
  • Groups did not differ significantly in primary cause of cardiac arrest
    • Hypotension (42, 47, 37)
    • Respiratory failure (35, 32,38)
    • Myocardial ischemia (20, 23, 17)
    • Metabolic abnormality (12, 8, 15)
    • Arrhythmia NOS (7, 6, 8)

Interventions

  • Randomized to VRE vs. epinephrine-placebo therapy

Outcomes

Comparisons are intensive therapy vs. standard therapy.

Primary Outcomes

Secondary Outcomes

Subgroup Analysis

Adverse Events

Criticisms

Funding

Further Reading

http://jama.jamanetwork.com/article.aspx?articleid=1713589