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Multidrug Cocktail for In-Hospital Cardiac Arrest

Addition of steroids might provide significant benefit.

About 80% of patients with in-hospital cardiac arrest do not survive to hospital discharge, and the mortality rate is even higher in patients with refractory arrest. These authors hypothesized that adding treatment with vasopressin (for its effects on vascular tone) and corticosteroids (for their effect on systemic inflammatory response and organ dysfunction) to standard treatment with epinephrine would improve outcomes after in-hospital cardiac arrest.

In a European single-center, randomized, double-blind, placebo-controlled study, researchers enrolled 100 consecutive patients from various areas of the hospital, including the emergency department, who had refractory cardiac arrest (defined as asystole/pulseless electrical activity or arrest caused by ventricular tachycardia/fibrillation with no return of spontaneous circulation after 2 defibrillations). Patients randomized to the study group received standard advanced life support (ALS) with epinephrine (1 mg per cardiopulmonary resuscitation cycle) plus vasopressin (20 IU per CPR cycle) for the first five CPR cycles and methylprednisolone (40 mg) during the first cycle; patients with postresuscitation shock received hydrocortisone (300 mg daily) for 7 days. Patients randomized to the control group received standard ALS with epinephrine (1 mg per CPR cycle) and normal saline instead of all other active drugs.

Patients in the study group were significantly more likely than controls to survive to hospital discharge (19% vs. 4%) and to have return of spontaneous circulation for 15 minutes or longer (81% vs. 52%). Mean arterial pressure immediately after resuscitation and central venous oxygen saturation during 72 hours after resuscitation were higher in the study group than in the control group. Levels of plasma inflammatory markers were significantly lower in the study group than in the control group throughout the first week after randomization. Among 42 patients with postresuscitation shock, those in the study group were significantly more likely to survive to discharge than those in the control group (30% vs. 0%).

Comment: A 2008 European study of out-of-hospital refractory cardiac arrest showed no benefit from the addition of two doses of vasopressin to standard epinephrine, even among patients who received basic life support within 8 minutes and ALS within 12 minutes (JW Emerg Med Jul 2 2008). The vasopressin dose in that study was double the 20-IU dose used in the current study. Thus, one might reasonably conclude that the benefit observed in the current study results from the addition of steroids both during resuscitation and for postresuscitation shock. However, this one small study from a single hospital does not warrant including steroids in resuscitation protocols; for that step, we need much stronger evidence.

— J. Stephen Bohan, MD, MS, FACP, FACEP

Published in Journal Watch Emergency Medicine February 6, 2009

Citation(s):

Mentzelopoulos SD et al. Vasopressin, epinephrine, and corticosteroids for in-hospital cardiac arrest. Arch Intern Med 2009 Jan 12; 169:15.

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