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More ROSC with Vasopressin and Steroids? – The VAM-IHCA Trial

October 29, 2021

Written by Eriny Hanna

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Patients who suffered in-hospital-cardiac-arrest (IHCA) who received vasopressin and steroids were more likely to have return of spontaneous circulation (ROSC) than those who received placebo. However, there was no difference in thirty-day survival, favorable neurologic outcomes, or other health-related quality of life measures.

Why does this matter?
Thought to improve coronary perfusion and reduce the systemic inflammatory response, vasopressin and steroids, respectively, have been theorized to increase the likelihood ROSC and improve outcomes after cardiac arrest. If this was shown to be true, it would be practice changing, and ACLS guidelines would need to be rewritten.

Wait…there are more meds to memorize for ACLS?
In this multicenter, randomized, double-blind, placebo-controlled trial, 501 adult patients with in-hospital cardiac arrest who received at least 1 dose of epinephrine during the arrest were randomized to additional administration of vasopressin (20 IU) and methylprednisolone (40 mg) (n = 237), versus normal saline placebo (n = 264). Up to 4 additional doses of vasopressin (20 IU) or placebo were administered after each additional epinephrine.

One hundred patients (42%) in the intervention group and 86 patients (33%) in the placebo group achieved ROSC (RR 1.30, 95% CI, 1.03-1.63). Thirty-day survival was 9.7% (23/237) in the intervention group and 12% (31/264) in the placebo group (RR 0.83, 95% CI, 0.50-1.37). Favorable neurologic scores did not differ (7.6% for both) between groups.

A big limitation of this study was the lack of controlling post-ROSC management. The placebo group received steroids significantly more than the intervention group (46% vs 24%), and twice as many patients in the placebo group received ECMO (30% vs 14%).

Currently the 2015 AHA guidelines state that vasopressin/ methylprednisolone may be considered in cardiac arrest, but more studies are needed to recommend routine use. I will continue to focus more on my team’s adherence to an excellent chest compression fraction than trying to add in more steps and meds to my ACLS algorithm.

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 Sep 29;e2116628. doi: 10.1001/jama.2021.16628. Online ahead of print.

What are your thoughts?