Steroids and Vasopressin in Cardiac Arrest?

Use of steroids in cardiac arrest is only weakly recommended by the current AHA guideline.

Vasopressin is totally banned from current AHA guideline due to lack of benefit with use with epinephrine compared to epinephrine alone.

But how about VSE combination? Are there benefits of using this combination in patients with cardiac arrest compared to epinephrine alone?

Mentzelopoulos et al conducted a 3-center, randomized, double-blind, placebo-controlled, parallel-group clinical trial that looked at this question.

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This study clearly showed the benefit of using VSE combination

  • ROSC: NNT = 5
  • Survival to discharge with good neuro recovery:
    – All patients NNT = 11
    – Post-resus shock = 8
  • Compared with control patients, VSE patients had higher mean arterial pressure during and after CPR.
    – During CPR, mean MAP in VSE group was 75.6mmHg (26.9%) vs in control group 52.2mmHg (16.9%), p= <.001
    – 20 mins after CPR, mean MAP in VSE group was 93.7mmhg (31.3%) vs in control group 69.1mmHg (20.4%), p= <.001
  • Regarding adverse effect, higher numbers of patientdays with insulin treatment aimed at a blood glucose level of
    180 mg/dL or less (249/494 patient-days [50.4%] vs 130/361 patient-days [36.0%]; P < .001).

Comments:

  1. This is a study of IHCA. Time to ALS initiation is 2 minutes, within the 5 minutes window of cardiac arrest. Whether VSE will have similar effect in OHCA in which time to CPR is often delayed remains the be seen. Also, compared to IHCA, OHCA often has suboptimal bystander’s CPR and this seriously affects the outcome of the patient.
  2. This is only a study in 238 patients in 3 centers. However, results were promising and importantly not many drugs improve survival to discharge with intact neuro recovery in cardiac arrest.
    – Epinephrine improves ROSC but not survival to DC with good neuro recovery.
    – In fact, concern that epinephrine may cause brain ischemia from vasoconstriction that worsens the neuro function in resuscitated patients.
  3. Long term outcome of VSE group patients after hospital discharge is not evaluated in this study.

Physiologic rationale

  1. Steroid as a stress hormone, potentiate the effect of vasopressors.
  2. Patient with shock will have an inflammatory condition similar to sepsis in post-ROSC. Steroids may attenuate the inflammatory response.

Read more in: http://rebelem.com/why-you-should-more-than-consider-a-vasopressin-steroid-and-epinephrine-vse-cocktail/

Reference:

  • Mentzelopoulos 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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