Critical Care Pharmacist with special interests in trauma and surgery.
Dave is an associate professor at Duquesne University School of Pharmacy and emergency medicine pharmacist at UPMC Mercy Hospital. He completed residency training at The Johns Hopkins Hospital and Maimonides Medical Center in Brooklyn, NY. His practice interests include medication dosing in patients that are obese and pain management in the ED. Find him on Twitter @DEZ_EM_Pharm
The Pre-brief
You are on a rapid response team heading to an inpatient cardiac arrest. ACLS is started and the first pulse-check shows no pulse and the patient is in asystole. Compressions are resumed and epinephrine 1mg IV is given to the patient. While going through the H’s and T’s, a team member suggests using vasopressin and methylprednisolone during the code. Is there evidence that this will be beneficial?
What’s the rationale?
After cardiac arrest, cortisol levels can drop to undesired levels, which is necessary to maintain adequate hemodynamics. Vasopressin increases vital organ blood flow, which may be beneficial to improve outcomes during cardiac arrest. The combination of these agents with epinephrine could theoretically improve patient outcomes from cardiac arrest.
But what does the literature says?
Mentzelopoulos et al published two randomized controlled trials(1,2) comparing the addition of vasopressin (20 units) and one dose of methylprednisolone (40 mg) with epinephrine during cardiac arrest versus placebo. The more recent trial found a statistically significant difference in favorable neurological outcomes at hospital discharge (18/130 [13.9%] vs 7/138 [5.1%]; OR, 3.28; 95% CI, 1.17-9.20; P = .02), favoring use of vasopressin and methylprednisolone with epinephrine. Despite these results, this regimen is not included as standard of care during ACLS.
Recently, a larger trial sought to further explore the benefits the use of vasopressin and methylprednisolone in cardiac arrest:
The Debrief
-Vasopressin was removed from the ACLS algorithm in 2015 based on insufficient evidence to support its use and to improve algorithm simplicity.
-Recent evidence showed that the combination of VAM has shown to statistically improve ROSC during an IHCA but did not show improved survival at 30 or 90 days, or favorable neurologic outcomes.
-Larger trials are needed to determine if we should be including vasopressin and methylprednisolone as part of ACLS standard of care.
References
- Mentzelopoulos SD, Zakynthinos SG, Tzoufi M, et al. Vasopressin, epinephrine, and corticosteroids for in-hospital cardiac arrest.Arch Intern Med. 2009;169(1):15-24. doi:10.1001/archinternmed.2008.5097
- Mentzelopoulos SD, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. JAMA. 2013;310(3):270-279. doi:10.1001/jama.2013.7832
- Andersen LW, Isbye D, Kjærgaard J, et al. Effect of Vasopressin and Methylprednisolone vs Placebo on Return of Spontaneous Circulation in Patients With In-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2021;326(16):1586–159
