Vasopressin and Epinephrine vs. Epinephrine Alone in Cardiopulmonary Resuscitation

Description

The goal of the trial was to evaluate treatment with vasopressin and epinephrine compared with epinephrine alone among patients with an out-of-hospital cardiac arrest.

Hypothesis

Vasopressin and epinephrine will be more effective in improving survival.

Drugs/Procedures Used

Patients with cardiac arrest were randomized to 40 IU vasopressin and 1 mg epinephrine (n =1,442) versus placebo and 1 mg epinephrine (n = 1,452). Study drugs were re-administered if there was no return in spontaneous circulation within 3 minutes. Defibrillation was attempted up to 3 times before randomization among patients who presented with ventricular fibrillation (VF).

Principal Findings

Overall, 2,956 patients underwent randomization. There were 62 patients excluded after randomization: 26 did not provide informed consent, 29 had traumatic cardiac arrest, and 7 did not meet other inclusion criteria. Baseline characteristics were well-matched, except that there were more men in the vasopressin and epinephrine group (75.4% vs. 71.7%, p = 0.03). The initial cardiac rhythm was VF in 9.2% versus 9.3%, pulseless electrical activity in 7.7% versus 8.3%, and asystole in 83.1% versus 82.4%, respectively. The time to arrival of emergency medical technicians was 7.2 minutes versus 6.8 minutes, and the total duration of advanced cardiac life support was 38.0 minutes versus 37.6 minutes, respectively.

The primary outcome, survival to hospital admission, occurred in 20.7% of the combination treatment group compared with 21.3% of the epinephrine alone group (p = 0.69). Return of spontaneous circulation occurred in 28.6% versus 29.5% (p = 0.62), survival to hospital discharge occurred in 1.7% versus 2.3% (p = 0.24), 1-year survival occurred in 1.3% versus 2.1% (p = 0.09), and good neurological recovery at hospital discharge occurred in 37.5% versus 51.5% (p = 0.29), respectively, for combination treatment versus epinephrine alone. Among patients who presented with pulseless electrical activity, survival to hospital discharge was 0% versus 5.8% (p = 0.02), respectively. There was no difference in this outcome among patients with VF or asystole.

Interpretation

The prognosis among patients who suffer an out-of-hospital cardiac arrest, especially asystole, remains grim. The combination of vasopressin and epinephrine is not superior to epinephrine alone in improving clinical outcomes. Specifically, there was no difference in survival to hospital admission or discharge, return in spontaneous circulation, good neurological recovery, or 1-year survival between the treatment groups. The finding of decreased survival to hospital discharge among the combination treatment group should only be considered hypothesis generating.

Conditions

• Arrhythmias / Ventricular fibrillation

Therapies

• Medical

Study Design

Randomized. Blinded. Parallel. Stratified.

Patients Enrolled: 2,956

Mean Follow-Up: 1 year

Mean Patient Age: 62 years

% Female: 27

Primary Endpoints

Survival to hospital admission. Survival was defined as a palpable pulse and measurable blood pressure upon arrival to an intensive care unit.

Secondary Endpoints

Return of spontaneous circulation

Survival to hospital discharge

Good neurological recovery

Survival at 1 year

Patient Population

Adult patients with a cardiac arrest due to VF, pulseless electrical activity, or asystole

Exclusions:

Age less than 18 years

Successful defibrillation without the need for vasopressor therapy

Traumatic cardiac arrest

Known pregnancy

Documented terminal illness

Do-not-resuscitate order

Sign of an irreversible cardiac arrest

Source : http://www.medscape.com/viewarticle/582270