Epinephrine, vasopressin and steroids for in-hospital cardiac arrest: the right cocktail therapy?

Buddineni, Jaya P.; Callaway, Clifton W.; Huang, David T.

doi:10.1186/cc13903

Cited by 9 publications

(6 citation statements)

References 18 publications

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“…In addition, release of adrenal hormone is frequently impaired after cardiac arrest, which reduces the physiologic stress response (70,71). Finally, steroids may increase response to vasopressors due to their effect on intracellular signaling pathways (72). Notably, the protocol investigated by Mentzelopoulos et al (16) does not allow to distinguish between effects of steroids administration during versus after CPR, as patients in the treatment groups received steroids in both phases.…”

Section: Discussionmentioning

confidence: 99%

Vasopressors During Cardiopulmonary Resuscitation. A Network Meta-Analysis of Randomized Trials

Belletti

Benedetto

Putzu

et al. 2018

Critical Care Medicine

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OBJECTIVES Several randomized controlled trials have compared adrenaline (epinephrine) with alternative therapies in patients with cardiac arrest with conflicting results. Recent observational studies suggest that adrenaline might increase return of spontaneous circulation but worsen neurologic outcome. We systematically compared all the vasopressors tested in randomized controlled trials in adult cardiac arrest patients in order to identify the treatment associated with the highest rate of return of spontaneous circulation, survival, and good neurologic outcome. DESIGN Network meta-analysis. PATIENTS Adult patients undergoing cardiopulmonary resuscitation. INTERVENTIONS PubMed, Embase, BioMed Central, and the Cochrane Central register were searched (up to April 1, 2017). We included all the randomized controlled trials comparing a vasopressor with any other therapy. A network meta-analysis with a frequentist approach was performed to identify the treatment associated with the highest likelihood of survival. MEASUREMENTS AND MAIN RESULTS Twenty-eight studies randomizing 14,848 patients in 12 treatment groups were included. Only a combined treatment with adrenaline, vasopressin, and methylprednisolone was associated with increased likelihood of return of spontaneous circulation and survival with a good neurologic outcome compared with several other comparators, including adrenaline. Adrenaline alone was not associated with any significant difference in mortality and good neurologic outcome compared with any other comparator. CONCLUSIONS In randomized controlled trials assessing vasopressors in adults with cardiac arrest, only a combination of adrenaline, vasopressin, and methylprednisolone was associated with improved survival with a good neurologic outcome compared with any other drug or placebo, particularly in in-hospital cardiac arrest. There was no significant randomized evidence to support neither discourage the use of adrenaline during cardiac arrest.

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Section: Discussionmentioning

confidence: 99%

Vasopressors During Cardiopulmonary Resuscitation. A Network Meta-Analysis of Randomized Trials

Belletti

Benedetto

Putzu

et al. 2018

Critical Care Medicine

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“…First, and most importantly, the study by Mentzelopoulos et al included multiple interventions in the treatment arm both during and after the cardiac arrest. As such, it is difficult to make firm conclusions about any specific interventions [ 38 ]. Second, the patient populations differ substantially between studies (for example, we enrolled 76 % out-of-hospital arrest patients whereas Mentzelopoulos et al enrolled only inpatients).…”

Section: Discussionmentioning

confidence: 99%

Corticosteroid therapy in refractory shock following cardiac arrest: a randomized, double-blind, placebo-controlled, trial

et al. 2016

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BackgroundThe purpose of this study was to determine whether the provision of corticosteroids improves time to shock reversal and outcomes in patients with post-cardiac arrest shock.MethodsWe conducted a randomized, double-blind trial of post-cardiac arrest patients in shock, defined as vasopressor support for a minimum of 1 hour. Patients were randomized to intravenous hydrocortisone 100 mg or placebo every 8 hours for 7 days or until shock reversal. The primary endpoint was time to shock reversal.ResultsFifty patients were included with 25 in each group. There was no difference in time to shock reversal between groups (hazard ratio: 0.83 [95 % CI: 0.40–1.75], p = 0.63). We found no difference in secondary outcomes including shock reversal (52 % vs. 60 %, p = 0.57), good neurological outcome (24 % vs. 32 %, p = 0.53) or survival to discharge (28 % vs. 36 %, p = 0.54) between the hydrocortisone and placebo groups. Of the patients with a baseline cortisol < 15 ug/dL, 100 % (6/6) in the hydrocortisone group achieved shock reversal compared to 33 % (1/3) in the placebo group (p = 0.08). All patients in the placebo group died (100 %; 3/3) whereas 50 % (3/6) died in the hydrocortisone group (p = 0.43).ConclusionsIn a population of cardiac arrest patients with vasopressor-dependent shock, treatment with hydrocortisone did not improve time to shock reversal, rate of shock reversal, or clinical outcomes when compared to placebo.Clinical trial registrationClinicaltrials.gov: NCT00676585, registration date: May 9, 2008.

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“…12 Recent clinical studies have shown that early administration of corticosteroids after CA can improve the success rate of ROSC, nervous system functional outcome and prognosis, which is speculated to be related to its influence on haemodynamics, and SIRS response, and other mechanisms. [12][13][14][15][16][17] Therefore, the role of GCs in the occurrence and development of PCAS needs to be studied further. GCs combine with intracellular GC receptors (GRs) to exert anti-inflammatory and immunosuppressive effects and reduce the production and the release of inflammatory cytokines.…”

Section: Strengths and Limitations Of This Studymentioning

confidence: 99%

Glucocorticoid receptor expression in patients with cardiac arrest in the early period after the return of spontaneous circulation: a prospective observational single-centre study

Tang

Xie

et al. 2022

BMJ Open

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ObjectivesRapid changes in glucocorticoid (GC) levels and adrenal insufficiency are related to the development of post-cardiac arrest (CA) syndrome. However, GC receptor (GR) expression changes have not been studied. Hence, this study aimed to investigate the association of early changes in GR expression and prognosis and immune response in patients who experienced CA.DesignProspective observational study.SettingEmergency department.ParticipantsPatients (85) in the early period of return of spontaneous circulation (ROSC) after CA were admitted between October 2018 and October 2019. After a physical examination, age-matched and sex-matched healthy individuals (40) were recruited for the control group.Primary and secondary outcome measuresGR expression and cell counts of circulatory T and B lymphocytes, natural killer cells and regulatory T (Treg) cells were assessed. Plasma total cortisol and adrenocorticotrophic hormone (ACTH) levels were also tested.ResultsAll cell counts were lower, and plasma total cortisol levels were higher (p<0.001) in patients who experienced CA than in the healthy control group. GR expression in Treg cells and CD3+CD4+ T lymphocytes were not significantly different, but the mean fluorescence intensity and GR expression in other cells were lower in patients who experienced CA (p<0.05) than in the healthy control group. ACTH levels were not different. There were no significant differences between survivors and non-survivors.ConclusionsThis study revealed that GR expression and cell counts rapidly decreased, whereas plasma total cortisol levels increased in the early period after ROSC among patients who experienced CA. Our findings provide important information about GR level and function, and immunosuppressive status in these patients. Assessing GR expression in patients who experienced CA may help screening for those who are more sensitive to GC therapy.

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Epinephrine, vasopressin and steroids for in-hospital cardiac arrest: the right cocktail therapy?

Cited by 9 publications

References 18 publications

Vasopressors During Cardiopulmonary Resuscitation. A Network Meta-Analysis of Randomized Trials

Vasopressors During Cardiopulmonary Resuscitation. A Network Meta-Analysis of Randomized Trials

Corticosteroid therapy in refractory shock following cardiac arrest: a randomized, double-blind, placebo-controlled, trial

Glucocorticoid receptor expression in patients with cardiac arrest in the early period after the return of spontaneous circulation: a prospective observational single-centre study

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