1 / 27

Enhancing Neurologically Favorable Survival in In-Hospital Cardiac Arrest: Insights from Vasopressin and Epinephrine

This study examines the impact of vasopressin, steroids, and epinephrine on neurologically favorable survival rates following in-hospital cardiac arrest. With alarming survival statistics and a focus on improving outcomes, the research leverages data from a randomized controlled trial involving 268 patients across three Greek hospitals. By analyzing return of spontaneous circulation (ROSC) and discharge outcomes, the findings underscore the potential benefits of innovative drug combinations, challenging existing protocols and advocating for refined resuscitation algorithms.

zinnia
Download Presentation

Enhancing Neurologically Favorable Survival in In-Hospital Cardiac Arrest: Insights from Vasopressin and Epinephrine

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrestMentzelopoulos, et al. By Greg Gipson 8/30/13

  2. The cardiac arrest problem • Out-of-hospital • US survival rate 11.4% • King County survival rate 52% • In-hospital • Estimated 6.7 per 1000 admissions • 200,000 patients/year • Neurologic damage • Survival to discharge 24.2% • Still room for improvement American Heart Association, http://www.heart.org/HEARTORG/, accessed 8/27/13 EMS 2012 Annual Report, available at www.kingcounty.gov/health/ems, accessed 8/27/13

  3. Standard of care AHA 2010 algorithm • CPR • Shock • Drugs • Epi 1mg q3-5min • Vasopressin 40 IU • Amio 300mg • Repeat 150mg • Return of spontaneous circulation (ROSC) American Heart Association, http://www.heart.org/HEARTORG/, accessed 8/27/13

  4. Challenging the Status Quo Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest • Previous trial showed benefit • RCT, single center, n=100 • ↑ROSC, ↑survival to discharge, similar ADEs • Neurologically survival ≠ survival • Further investigate treatment algorithm • Published: JAMA - July 2013 Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. JAMA 2013;310(3):270-279. Mentzelopoulos S, Zakynthinos S, Tzoufi M, et al. Vasopressin, epinephrine, and corticosteroids for in-hospital cardiac arrest

  5. Study Design • RC, DB, PC, parallel-group, MC • Pharmacists randomized • Sept 1, 2008 – Oct 1, 2010 • 3 Greek tertiary care hospitals • N=268 consecutive patients • Exclusion • <18 y/o, terminal illness, DNR, exsanguination, arrest before admission, IV steroids, previous enrollment/exclusion Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. JAMA 2013;310(3):270-279.

  6. Protocol • Cardiac arrest! • Begin CPR (30:2) • Intervention q 3 minutes, x 5 times • Tx: Vasopressin 20 IU and epi 1mg • Control: Saline placebo and epi 1mg • First cycle ONLY • Tx: Methyprednisolone 40mg IV • Control: Saline placebo Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. JAMA 2013;310(3):270-279.

  7. Protocol • No ROSC by 5th cycle • Follow European resuscitation guidelines • Epi 1mg q3-5min • Option: Amio, atropine, magnesium Nolan JP, Deakin CD, Soar J. European resuscitation council. European resuscitation council guidelines for resuscitation 2005: Section 4, Adult advanced life support. Resuscitation. 2005;37(suppl 1):@39-S86

  8. Protocol • 4 hours post resuscitation • Postresuscitation shock? • Tx: Hydrocortisone 300 mg/d CI, ≤ 7 days, then taper • Unless AMI, then ≤ 3 days • Control: Saline infusions • Could receive open-label hydrocortisone Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. JAMA 2013;310(3):270-279.

  9. Outcomes • Primary • ROSC x ≥20 minutes • Survival to discharge w/ CPC 1 or 2 • Secondary • Atrial pressure 20 min post ROSC • Atrial pressure + ScvO2 (days 1-10) • Organ failure free days (days 1-60) • Corticosteroid complications • Hyperglycemia, infection, PUD, paresis Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. JAMA 2013;310(3):270-279. Grenvik A, Safar P. Eds: Brain failure and resuscitation, Churchill Livingstone, New Yortk, 1981; 155-184.

  10. Analysis • Power calculations • N=244 • ITT • Tested • Normality • Heterogeneity • Analysis methods • Chi2 or Fischer exact • T-tests • Linear-mixed model • Logistic regression • Multivariate Cox Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. JAMA 2013;310(3):270-279.

  11. Results • Figure 1 Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. JAMA 2013;310(3):270-279.

  12. Results • Comparable baseline characteristics Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. JAMA 2013;310(3):270-279.

  13. Results Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. JAMA 2013;310(3):270-279.

  14. Results Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. JAMA 2013;310(3):270-279.

  15. Results Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. JAMA 2013;310(3):270-279.

  16. Results Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. JAMA 2013;310(3):270-279.

  17. Results Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. JAMA 2013;310(3):270-279.

  18. Results Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. JAMA 2013;310(3):270-279.

  19. Results • MAP higher on days 1, 2, 4, 5, 10 post resuscitation • ScvO2 higher on days 1, 2, 4-10 post resuscitation Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. JAMA 2013;310(3):270-279.

  20. Results • More organ failure free days and ventilator free days in treatment group Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. JAMA 2013;310(3):270-279.

  21. Results • Adverse events from corticosteroids • Tx group • Used more insulin (p<0.001) • No difference in hyperglycemia (>180mg/dL, p=0.88) • No other ADEs reported Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. JAMA 2013;310(3):270-279.

  22. Discussion • Epinephrine • Adrenergic agonist • Vasoconstriction • ↑Cerebral perfusion • ↑Coronary perfusion • ↑HR, ↑CO • ↑Cerebral perfusion • ↑Coronary perfusion • ↑Myocardial O2 consumption • Effect attenuated in hypoxia and acidosis • T1/2 = 2-3 min • Peak concentration ~90 sec Papastylianou A, Mentzelopoulos S. Current pharmacological advances in the treatment of cardiac arrest. Emergency Medicine International 2012,815857;9.

  23. Discussion • Vasopressin • Vasopressin receptor agonist (V1,2,3) • V1 – Vasoconstriction • ↑ Cerebral perfusion • V2 – Antidiuresis (distal convoluted tubule, medullary collecting duct) • V3 – Insulin, ACTH, temp, BP, memory (anterior pituitary, islet cells) • Survivors show low vasopressin levels • T1/2 = 10-35 min • Data shows: Vasopressin = Epi Papastylianou A, Mentzelopoulos S. Current pharmacological advances in the treatment of cardiac arrest. Emergency Medicine International 2012,815857;9. Image from: MCAT Review, http://mcatprep4free.blogspot.com/2011/08/antidiuretic-hormone-adh.html, Accessed 8/28/13

  24. Discussion • Corticosteroids • Use is controversial • Adrenal dysfunction possible in shock • Not standard of practice for cardiac resuscitation • ↑ effect of epinephrine • ↑ effect of vasopressin • ↑ myocardial function post arrest • Other possibly beneficial effects • Anti-inflammatory • Increase fluid volume • ADEs Patel G, Balk R. Systemic steroids in severe sepsis and septic shock. American Journal of Respiratory and Critical Care Medicine. 2012;2:133-139 Skyschally A, Haude M, Dorge H, et al. Glucocorticoid treatment prevents progressive myocardial dysfunction resulting from experimental coronary microembloism. Circulation 2004;109(19):2337-2342. Mentzelopoulos S, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. JAMA 2013;310(3):270-279. Image from: http://images.ddccdn.com/drp/images/12/80007201.jpg, Accessed 8/28/13

  25. Summary • VSE • ↑ ROSC • ↑ Survival and neurologic outcomes • ↑ Hemodynamics • ↓ Organ failure • ? Corticosteroid complications • ↑ Insulin use • ↔ Hyperglycemia

  26. Discussion • Can we safely apply these results to a US population? • Should we repeat this trial in King County? • What will the next AHA ACLS guidelines recommend? • Will they incorporate this data?

  27. Questions

More Related