Efficacy and Safety of Corticosteroids in Cardiac Arrest: A Systematic Review, Meta- Analysis and Trial Sequential Analysis of Randomized Control Trials

Abstract

Background Post cardiac arrest, outcomes for most patients are poor, regardless of setting. Many patients who do achieve spontaneous return of circulation require vasopressor therapy to maintain organ perfusion. There is some evidence to support the use of corticosteroids in cardiac arrest. Research Question: Assess the efficacy and safety of corticosteroids in patients following in and out of hospital cardiac arrest. Study Design & Methods: We searched databases CINAHL, EMBASE, LILACS, MEDLINE, Web of Science, CENTRAL, ClinicalTrails.gov, and ICTRP. We included randomized controlled trials (RCTs) that examined the efficacy and safety of corticosteroids, as compared to placebo or usual care in patients post cardiac arrest. We pooled estimates of effect size using random effects meta-analysis and report relative risk (RR) with 95% confidence intervals (CIs). We assessed risk of bias (ROB) for the included trials using the modified Cochrane ROB tool and rated the certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation methodology (GRADE). Results We included 8 RCTs (n = 2,213 patients). Corticosteroids administered post cardiac arrest had an uncertain effect on mortality measured at the longest point of follow-up (RR 0.96, 95% CI 0.90 to 1.02, very low certainty, required information size not met using trial sequential analysis). Corticosteroids probably increase return of spontaneous circulation (ROSC) (RR 1.32, 95% CI 1.18 to 1.47, moderate certainty) and may increase the likelihood of survival with good functional outcome (RR 1.49, 95% CI 0.87 to 2.54, low certainty). Corticosteroids may increase the risk of ventilator associated pneumonia (RR 0.76, 95% CI 0.46 to 1.09, low certainty) and renal failure (RR 1.29, 95% CI 0.84 to 1.99, low certainty) with an uncertain effect on bleeding (RR 2.04, 95% CI 0.53 to 7.84, very low certainty) and peritonitis (RR 10.54, 95% CI 2.99 to 37.19, very low certainty). Conclusions In patients post cardiac arrest, corticosteroids have an uncertain effect on mortality but may increase ROSC and the likelihood of survival with good functional outcome. The effect on complications is based on low or very low certainty evidence.