CARING FOR THE CRITICALLY ILL PATIENT Vasopressin , Steroids , and Epinephrine and Neurologically Favorable Survival After In-Hospital Cardiac Arrest A Randomized Clinical Trial FREE

ABSTRACT | METHODS | RESULTS | DISCUSSION | CONCLUSIONS || METHODS | RESULTS | DISCUSSION | CONCLUSIONS | ARTICLE INFORMATION | REFERENCES Importance 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, Setting, and Participants Randomized, double-blind, placebo-controlled, parallel-group trial performed from September 1, 2008, to October 1, 2010, in 3 Greek tertiary care centers (2400 beds) with 268 consecutive patients with cardiac arrest requiring epinephrine according to resuscitation guidelines (from 364 patients assessed for eligibility). Interventions 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). Main Outcomes and Measures Return of spontaneous circulation (ROSC) for 20 minutes or longer and survival to hospital discharge with a CPC score of 1 or 2. Results Follow-up was completed in all resuscitated patients. Patients in the VSE group vs patients in the control group had higher probability for ROSC of 20 minutes or longer (109/130 [83.9%] vs 91/138 [65.9%]; odds ratio [OR], 2.98; 95% CI, 1.39-6.40; P = .005) and survival to hospital discharge with CPC score of 1 or 2 (18/130 [13.9%] vs 7/138 [5.1%]; OR, 3.28; 95% CI, 1.17-9.20; P = .02). Patients in the VSE group with postresuscitation shock vs corresponding patients in the control group had higher probability for survival to hospital discharge with CPC scores of 1 or 2 (16/76 [21.1%] vs 6/73 [8.2%]; OR, 3.74; 95% CI, 1.20-11.62; P = .02), improved hemodynamics and central venous oxygen saturation, and less organ dysfunction. Adverse event rates were similar in the 2 groups. Conclusion and Relevance Among patients with cardiac arrest requiring vasopressors, combined vasopressin-epinephrine and methylprednisolone during CPR and stress-dose hydrocortisone in postresuscitation shock, compared with epinephrine/saline placebo, resulted in improved survival to hospital discharge with favorable neurological status. Trial Registration clinicaltrials.gov Identifier: NCT00729794 Neurological outcome after cardiac arrest has been the main end point of several randomized clinical trials (RCTs).14 Neurologically favorable survival differs from overall survival. Among cardiac arrest survivors, the prevalence of severe cerebral disability or vegetative state ranges from 25% to 50%.26 In a previous single-center RCT,7 combined vasopressin-epinephrine during cardiopulmonary resuscitation (CPR) and corticosteroid supplementation during and after CPR vs epinephrine alone during CPR and no steroids resulted in improved overall survival to hospital discharge. Patients in the vasopressin-steroids-epinephrine (VSE) group had more frequent return of spontaneous circulation (ROSC) and attenuated postresuscitation systemic inflammatory response7,8 and organ dysfunction.7 However, this preliminary study could not reliably assess VSE efficacy with respect to neurologically favorable survival to hospital discharge. We addressed this question with a 3-center RCT of vasopressorrequiring, in-hospital cardiac arrest.