ArticlesVasopressin versus epinephrine for inhospital cardiac arrest: a randomised controlled trial
Introduction
There are an estimated 300 000 cardiac arrests yearly in patients in hospital throughout Canada and USA.1 We have previously recorded2 that the survival rate of hospital patients who required epinephrine was only 6%. Results of clinical trials have failed to show improved survival with high doses of epinephrine and other adrenergic agents (phenylephrine and methoxamine). Because of the high drug concentrations required and the potential side-effects of adrenergic agents, non-adrenergic vasoactive drugs are sought to maintain vascular tone and blood flow during cardiac arrest.
Several laboratory and clinical studies have documented high concentrations of endogenous vasopressin during cardiac arrest.3, 4 Additionally, Lindner and colleagues5 showed that arginine vasopressin increased arterial and coronary pressures as well as myocardial and cerebral blood flows compared with standard doses of epinephrine in experimental models of cardiac arrest. In two small case series,6, 7 patients failed standard epinephrine therapy but survived after receiving vasopressin. In one randomised controlled clinical trial,8 the investigators compared the effect of 40 U vasopressin with 1 mg epinephrine in 40 prehospital patients who had not responded to three countershocks. Compared with epinephrine, the group that received vasopressin had a 50% increase in the number of admitted patients and a 66% increase in patients alive at 24 h.
The American Heart Association (AHA) Advanced Cardiac Life Support (ACLS) guidelines9 recommend vasopressin as an alternative to epinephrine for treatment of cardiac arrest. This recommendation could lead to use of vasopressin for millions of cardiac arrests worldwide. We did a randomised controlled clinical trial of vasopressin or epinephrine as the initial vasopressor, to compare survival outcomes and safety for patients who had cardiac arrest in hospital.
Section snippets
Patients
We did our study in the emergency departments, critical care units, and general wards of two tertiary-care hospitals affiliated with the University of Ottawa, Ottawa, Canada, and with one tertiary hospital affiliated with the University of Western Ontario in London. Patients were eligible if they were admitted to hospital, had a cardiac arrest, and required epinephrine according to AHA ACLS protocols for asystole, pulseless electrical activity, or refractory ventricular fibrillation. We
Results
From July 3, 1997, to Nov 30, 1998, we enrolled and successfully followed up 200 patients (figure). During the trial, a further 50 eligible patients were not entered into the study by attending clinicians because of the urgency and stress of treating an immediately life-threatening condition. Clinical and demographic characteristics of these individuals were closely similar to those of the enrolled patients. Furthermore, 74 ineligible patients received the study drug and were excluded
Discussion
We failed to show any improvement with vasopressin compared with epinephrine for either short-term or long-term survival. Furthermore, in several clinically important subgroups, vasopressin was not associated with improved outcomes. We recognise that, because of our small sample size and the wide confidence intervals around the treatment effect estimates, our results do not exclude the possibility of a clinically important benefit for vasopressin. Nevertheless, we detected no trends favouring
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2022, American Journal of CardiologyFrequency of Medical Reversal Among Published Randomized Controlled Trials Assessing Cardiopulmonary Resuscitation (CPR)
2020, Mayo Clinic ProceedingsCitation Excerpt :Sixteen of the 44 (36%) reversal trials tested medications.6-21 Of these 44 trials, the largest subset comprised 5 (11%) trials that tested the use of vasopressin in concert with (or in partial substitution for) epinephrine during advanced cardiac life support (ACLS)6-10; 2 others investigated changes to epinephrine dosing.11,12 Two other medication reversals were directed to antiarrhythmics,13,14 and 2 were directed toward the use of thrombolytics.15,16