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Steroid-Pressor Cocktail for In-Hospital Cardiac Arrest?

September 24, 2013

Steroid-Pressor Cocktail for In-Hospital Cardiac Arrest?

  1. Daniel D. Dressler, MD, MSc, SFHM, FACP

This combination improved neurologically favorable survival.

  1. Daniel D. Dressler, MD, MSc, SFHM, FACP

Aside from aggressive chest compressions and early defibrillation, robust data are lacking on interventions to improve cardiac arrest outcomes. A small study in 2009 suggested improved surrogate outcomes with use of a vasopressin-steroids-epinephrine (VSE) combination for in-hospital cardiac arrest. These data prompted researchers in Greece to perform a randomized trial involving 300 in-hospital cardiac arrest patients who required at least one dose of epinephrine.

Patients received either VSE (20 units vasopressin and 1 mg epinephrine per 3-minute cycle for up to 5 cycles plus 40 mg methylprednisolone with the first dose of epinephrine) or placebo (saline) plus the standard 1 mg epinephrine dose during each 3-minute cycle. Postresuscitation shock was treated with stress-dose hydrocortisone in the VSE group versus saline in the control group. Patients who received VSE were significantly more likely to be alive at hospital discharge with neurologically favorable outcomes than controls (14% vs. 5%; number needed to treat [NNT], 11). Among 149 patients with return of spontaneous circulation who then developed postresuscitation shock, those in the VSE group were also significantly more likely than controls to be alive at hospital discharge with neurologically favorable outcomes (21% vs. 8%; NNT, 8).

Comment

This study represents a new milestone in interventions for cardiac arrest — a pharmaceutical combination that affects important patient-level outcomes. Effects may reflect improved periarrest hemodynamics and improved cerebral microcirculatory flow. This well-designed study warrants review for incorporation into cardiac resuscitation guidelines and clinical practice.

  • Disclosures for Daniel D. Dressler, MD, MSc, SFHM, FACP at time of publication Editorial boards Hospital Medicine Reviews; Journal of Hospital Medicine

Citation(s):

Reader Comments (4)

ALEXANDER HIEATT Physician, Emergency Medicine, Chelmsford Essex

A very well conducted study. There are however a combination of discrepancies between the two groups which may explain the difference in outcomes although none of these differences in isolation reaches the magic p=0.05. The control group were in hospital for a much shorter mean duration before arrest which may reflect that they had more rapidly progressive underlying pathology. Likewise there was an excess of patients with respiratory disease in the control group as well as an excess of patients in asystole.

JOHNNY MARINAS

The association of steroids during CPR should be introduced in resuscitation guidelines!

Andres Castillo-Saborio Physician, Internal Medicine, CCSS

Very interesting study, deserve more investigations.

Aaron Costerisan Physician, Family Medicine/General Practice, teaching institution

nice article

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