Addition of Vasopressin Plus Steroids to Epinephrine Increases Survival to Discharge with Favorable Neurologic Outcomes After In-Hosptial Cardiac Arrest

EBM Focus - Volume 8, Issue 30

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Reference: JAMA 2013 Jul 17;310(3):270, (level 1 [likely reliable] evidence)

The addition of vasopressin and steroids to epinephrine during resuscitation has previously been shown to improve survival following in-hospital cardiac arrest compared to epinephrine alone (Arch Intern Med 2009 Jan 12;169(1):15). A new randomized trial further assessed the efficacy of combined treatment with vasopressin plus steroids in addition to epinephrine in 300 adult patients with in-hospital cardiac arrest.

Patients with in-hospital cardiac arrest requiring epinephrine by European resuscitation guidelines were randomized to vasopressin plus steroids plus epinephrine (VSE) vs. epinephrine alone during resuscitation and were followed until death or hospital discharge. The VSE group received vasopressin 20 units/cycle plus epinephrine 1 mg/cycle for the first 5 resuscitation cycles plus methylprednisolone 40 mg on first cycle. The epinephrine alone group had epinephrine 1 mg/cycle plus normal saline placebo for the first 5 cycles. All patients could receive additional epinephrine as needed. Patients in the VSE group who had postresuscitation shock also received hydrocortisone IV 300 mg daily for up to 7 days with gradual taper (patients in the epinephrine group with postresuscitation shock received placebo saline.) Favorable neurologic outcome was defined as a Cerebral Performance Category score of 1 (conscious, alert, and able to work, with possible mild neurologic or psychologic deficit) or 2 (moderate disability, but sufficient cerebral function for independent activities of daily life).

The intention to treat analysis included all patients who received the allocated treatment (Sixteen patients in each group had confirmed return of spontaneous circulation before administration of study treatment and were excluded from analyses.) The rate of survival to discharge with favorable neurological outcome was 13.9% with VSE vs. 5.1% with epinephrine alone (p = 0.02, NNT 12). VSE was also associated with a higher rate of return of spontaneous circulation for at least 20 minutes (83.9% vs. 65.9%, p = 0.005, NNT 6). In a subgroup analysis of 149 patients who had postresuscitation shock, 21.1% of the VSE group and 8.2% of the epinephrine group survived to discharge with good neurologic outcome (p = 0.02, NNT 8). There were no significant differences in the rates of complications, postarrest morbidity, or causes of death in analysis of 162 patients who survived ≥4 hours.

For more information, see the Cardiac arrest topic in DynaMed.