EBQ:A comparison of Vasopressin and Epinephrine for Out-of-Hospital Cardiopulmonary Resuscitation

incomplete Journal Club Article
Volker Wenzel, M.D., Anette C. Krismer, M.D., H. Richard Arntz, M.D., Helmut Sitter, Ph.D., Karl H. Stadlbauer, M.D., and Karl H. Lindner, M.D., for the European Resuscitation Council Vasopressor during Cardiopulmonary Resuscitation Study Group*. "A Comparison of Vasopressin and Epinephrine for Out-of-Hospital Cardiopulmonary Resuscitation". NEJM. 2004. 350(2):105-113.
PubMed PDF

Clinical Question

  • Does 2 injections of vasopressin 40 IU versus epinephrine 1mg followed by additional treatment of epinephrine if needed improve out-of-hospital cardiac arrest patients survival to hospital admission and hospital discharge?

Conclusion

  • In ventricular fibrillation (Vfib) and pulseless electrical activity, vasopressin and epinephrine have similar effects
  • In asystole, vasopressin is superior to epinephrine in patients with asystole
  • In refractory cardiac arrest, more prudent to use vasopressin then epinephrine over epinephrine alone

Major Points

Study Design

  • Double-blind, prospective, multicenter, randomized, controlled clinical trial
  • Conducted from June 1999-March 2002
  • Patients were randomized in blocks of 10 with stratification based on center
  • if patient had PEA or asystole- immediate randomization
  • if patient had vfib had 3 unsuccessful defibrillation attempts- pt was then randomized
  • patient randomized then the provider opened the study drug
    • 2 ampules of 1 mg of epinephrine or 2 ampules of 40 IU of vasopressin
  • provider gives one ampule of drug if no ROSC, same drug was given again
    • if still no ROSC can give additional Epinephrine injections
  • Drugs given IV
  • unknown of the study drug assignment unless it was necessary for management after the resusucitation.
  • other interventions given at physician discretion ie- atropine, lidocaine, amiodarone, sodium bicarbonate, fibrinolysis


Population

  • 33 communities in Austria, Germany, and Switzerland

Patient Demographics

Inclusion Criteria

  • adult patients who had an out-of-hospital cardiac arrest and presented with ventricular fibrillation, pulseless electrical activity, or asystole requiring CPR with vasopressor therapy

Exclusion Criteria

  • successful defibrillation without the administration of a vasopressor
  • documented terminal illness
  • lack of intravenous access
  • hemorrhagic shock
  • pregnancy
  • cardiac arrest after trauma
  • Age<18
  • presence of a do-not-resuscitate order.

Interventions

40IU Vasopressin 1mg of epinephrine


Outcomes

  • Improved survival to hospital admission
    • witnessed cardiac arrest
    • basic life support within 10 minutes
    • asystole with vasopressin as initial therapy
    • vasopressin as initial drug followed by epinephrine
    • amiodarone given
    • fibrinolysis given

Primary Outcome

  • hospital admission
    • Ventricular fibrillation (Epi/Vaso) 46.2%/43%
      • no significant difference
    • Pulseless electrical activity (Epi/Vaso) 33.7%/30.5%
      • no significant difference
    • Asystole (Epi/Vaso)29.0%/20.3%
      • significant difference

Secondary Outcomes

  • in patients that didn’t receive ROSC in giving more epi to patients the vasopressin group had a statistically significant improvements in survival to hospital admission 25.7% versus 16.4% and statistically significant improvements in survival to hospital discharge 6.2% versus 1.7%
  • Overall rate of survival to hospital discharge for all patients 9.7 %
  • 2.2 % of patients were comatose at hospital discharge
  • Best outcomes seen in patients that had BLS within 10 minutes of cardiac arrest and had a witnessed cardiac arrest

Criticisms & Further Discussion

  • Fewer patients randomized than intended
  • Survival to hospital admission isn’t the best outcome- unclear what type of neurologic
  • Cause of cardiac arrest cannot be verified and etiology could affect CPR success
  • No information if hypothermia could improve neurologic recovery
*currently no vasopressin in ACLS guidelines

External Links

http://emergencymedicinecases.com/acls-guidelines-2015-cardiac-arrest/

See Also

Funding

  • Supported in part by a Founders Grant for Training in Clinical Critical Care Research, Society of Critical Care Medicine, Des Plaines, Ill.; by Science Funds No. 7280 of the Austrian National Bank, Vienna, Austria; by the Dean's Office of the Leopold-Franzens University College of Medicine, Innsbruck, Austria; by the Laerdal Foundation for Acute Medicine, Stavanger, Norway; by an Austrian Science Foundation grant (P-14169-MED), Vienna, Austria; by Pfizer, Karlsruhe, Germany; by the Science Foundation of the Tyrolean State Hospitals, Innsbruck, Austria; and by the Department of Anesthesiology and Critical Care Medicine, Leopold-Franzens University, Innsbruck, Austria.

References

Authors:

Alison Panosian