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Ho JKM, Tam HL, Leung LYL. Effectiveness of Vasopressin Against Cardiac Arrest: A Systematic Review of Systematic Reviews. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07571-3. [PMID: 38470507 DOI: 10.1007/s10557-024-07571-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE This systematic review (SR) of SRs evaluates the effectiveness of vasopressin alone or in combination with other drugs in improving the outcomes of cardiac arrest (CA). METHODS Using a three-step approach, we searched five databases to identify all relevant SRs. Two reviewers independently selected suitable studies, assessed study quality, and extracted relevant data. If an outcome was reported by multiple SRs, a re-meta-analysis was conducted as needed; otherwise, a narrative analysis was performed. RESULTS Twelve SRs covering 16 original studies were included in this review. The meta-analysis results revealed a significant increase in survival to hospital admission for patients with in-hospital CA (IHCA) or out-of-hospital CA (OHCA) receiving vasopressin alone compared with that for those receiving epinephrine alone. Furthermore, the return of spontaneous circulation (ROSC) was significantly increased in patients with OHCA receiving vasopressin with epinephrine compared with that in those receiving epinephrine alone. Compared with patients with IHCA receiving epinephrine with placebo, those receiving vasopressin, steroids, and epinephrine (VSE) exhibited significant increases in ROSC, survival to hospital discharge, favorable neurological outcomes, mean arterial pressure, renal failure-free days, coagulation failure-free days, and insulin requirement. CONCLUSION VSE is the most effective drug combination for improving the short- and long-term outcomes of IHCA. It is recommended to use VSE in patients with IHCA. Future studies should investigate the effectiveness of VSE against OHCA and CA of various etiologies, the types and standard dosages of steroids for cardiac resuscitation, and the effectiveness of vasopressin-steroid in improving CA outcomes.
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Affiliation(s)
- Jonathan Ka-Ming Ho
- School of Nursing and Health Studies, Hong Kong Metropolitan University, Homantin, Kowloon, Hong Kong.
| | - Hon-Lon Tam
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Leona Yuen-Ling Leung
- School of Nursing and Health Studies, Hong Kong Metropolitan University, Homantin, Kowloon, Hong Kong
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2
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Fernando SM, Mathew R, Sadeghirad B, Rochwerg B, Hibbert B, Munshi L, Fan E, Brodie D, Di Santo P, Tran A, McLeod SL, Vaillancourt C, Cheskes S, Ferguson ND, Scales DC, Lin S, Sandroni C, Soar J, Dorian P, Perkins GD, Nolan JP. Epinephrine in Out-of-Hospital Cardiac Arrest: A Network Meta-analysis and Subgroup Analyses of Shockable and Nonshockable Rhythms. Chest 2023; 164:381-393. [PMID: 36736487 DOI: 10.1016/j.chest.2023.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/20/2023] [Accepted: 01/21/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Epinephrine is the most commonly used drug in out-of-hospital cardiac arrest (OHCA) resuscitation, but evidence supporting its efficacy is mixed. RESEARCH QUESTION What are the comparative efficacy and safety of standard dose epinephrine, high-dose epinephrine, epinephrine plus vasopressin, and placebo or no treatment in improving outcomes after OHCA? STUDY DESIGN AND METHODS In this systematic review and network meta-analysis of randomized controlled trials, we searched six databases from inception through June 2022 for randomized controlled trials evaluating epinephrine use during OHCA resuscitation. We performed frequentist random-effects network meta-analysis and present ORs and 95% CIs. We used the the Grading of Recommendations, Assessment, Development, and Evaluation approach to rate the certainty of evidence. Outcomes included return of spontaneous circulation (ROSC), survival to hospital admission, survival to discharge, and survival with good functional outcome. RESULTS We included 18 trials (21,594 patients). Compared with placebo or no treatment, high-dose epinephrine (OR, 4.27; 95% CI, 3.68-4.97), standard-dose epinephrine (OR, 3.69; 95% CI, 3.32-4.10), and epinephrine plus vasopressin (OR, 3.54; 95% CI, 2.94-4.26) all increased ROSC. High-dose epinephrine (OR, 3.53; 95% CI, 2.97-4.20), standard-dose epinephrine (OR, 3.00; 95% CI, 2.66-3.38), and epinephrine plus vasopressin (OR, 2.79; 95% CI, 2.27-3.44) all increased survival to hospital admission as compared with placebo or no treatment. However, none of these agents may increase survival to discharge or survival with good functional outcome as compared with placebo or no treatment. Compared with placebo or no treatment, standard-dose epinephrine improved survival to discharge among patients with nonshockable rhythm (OR, 2.10; 95% CI, 1.21-3.63), but not in those with shockable rhythm (OR, 0.85; 95% CI, 0.39-1.85). INTERPRETATION Use of standard-dose epinephrine, high-dose epinephrine, and epinephrine plus vasopressin increases ROSC and survival to hospital admission, but may not improve survival to discharge or functional outcome. Standard-dose epinephrine improved survival to discharge among patients with nonshockable rhythm, but not those with shockable rhythm. TRIAL REGISTRY Center for Open Science: https://osf.io/arxwq.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, ON, Canada; Department of Emergency Medicine, University of Ottawa, ON, Canada; CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Rebecca Mathew
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Behnam Sadeghirad
- Department of Anesthesia, Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence, and Impact, Department of Medicine, McMaster University, Hamilton, ON, Canada; Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Benjamin Hibbert
- Department of Cellular and Molecular Medicine, University of Ottawa, ON, Canada; CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, ON, Canada; Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, ON, Canada; Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY
| | - Pietro Di Santo
- Division of Critical Care, Department of Medicine, University of Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, ON, Canada; CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Alexandre Tran
- Division of Critical Care, Department of Medicine, University of Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, ON, Canada
| | - Shelley L McLeod
- Department of Health Research Methods, Evidence, and Impact, Department of Medicine, McMaster University, Hamilton, ON, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada
| | - Christian Vaillancourt
- Department of Emergency Medicine, University of Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sheldon Cheskes
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, ON, Canada; Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Steve Lin
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Claudio Sandroni
- Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, England
| | - Paul Dorian
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, Warwick University, Gibbet Hill, Coventry, England
| | - Jerry P Nolan
- Warwick Clinical Trials Unit, Warwick Medical School, Warwick University, Gibbet Hill, Coventry, England; Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, England
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3
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Wang C, Bischof E, Xu J, Guo Q, Zheng G, Ge W, Hu J, Georgescu Margarint EL, Bradley JL, Peberdy MA, Ornato JP, Zhu C, Tang W. Effects of Methylprednisolone on Myocardial Function and Microcirculation in Post-resuscitation: A Rat Model. Front Cardiovasc Med 2022; 9:894004. [PMID: 35872886 PMCID: PMC9301050 DOI: 10.3389/fcvm.2022.894004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPrevious studies have demonstrated that inflammation and impaired microcirculation are key factors in post-resuscitation syndromes. Here, we investigated whether methylprednisolone (MP) could improve myocardial function and microcirculation by suppressing the systemic inflammatory response following cardiopulmonary resuscitation (CPR) in a rat model of cardiac arrest (CA).MethodsSprague-Dawley rats were randomly assigned to (1) sham, (2) control, and (3) drug groups. Ventricular fibrillation was induced and then followed by CPR. The rats were infused with either MP or vehicle at the start of CPR. Myocardial function and microcirculation were assessed at baseline and after the restoration of spontaneous circulation. Blood samples were drawn at baseline and 60-min post-resuscitation to assess serum cytokine (TNF-α, IL-1β, and IL-6) levels.ResultsMyocardial function [estimated by the ejection fraction (EF), myocardial performance index (MPI), and cardiac output (CO)] improved post-ROSC in the MP group compared with those in the control group (p < 0.05). MP decreased the levels of the aforementioned pro-inflammatory cytokines and alleviated cerebral, sublingual, and intestinal microcirculation compared with the control (p < 0.05). A negative correlation emerged between the cytokine profile and microcirculatory blood flow.ConclusionMP treatment reduced post-resuscitation myocardial dysfunction, inhibited pro-inflammatory cytokines, and improved microcirculation in the initial recovery phase in a CA and resuscitation animal model. Therefore, MP could be a potential clinical target for CA patients in the early phase after CPR to alleviate myocardial dysfunction and improve prognosis.
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Affiliation(s)
- Changsheng Wang
- Department of Emergency Medicine, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
| | - Evelyne Bischof
- Department of Basic and Clinical Medicine, Shanghai University of Medicine and Health Sciences, Shanghai, China
- Department of Medical Oncology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jing Xu
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
| | - Qinyue Guo
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
| | - Guanghui Zheng
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
| | - Weiwei Ge
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
| | - Juntao Hu
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
| | | | - Jennifer L. Bradley
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
| | - Mary Ann Peberdy
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
- Department of Internal Medicine and Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, United States
| | - Joseph P. Ornato
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
- Department of Internal Medicine and Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, United States
| | - Changqing Zhu
- Department of Emergency Medicine, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Changqing Zhu,
| | - Wanchun Tang
- Weil Institute of Emergency and Critical Care Research, Virginia Commonwealth University, Richmond, VA, United States
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, United States
- Wanchun Tang,
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Rafiei H, Bahrami N, Meisami AH, Azadifar H, Tabrizi S. The effect of epinephrine and methylprednisolone on cardiac arrest patients. Ann Med Surg (Lond) 2022; 78:103832. [PMID: 35734658 PMCID: PMC9206913 DOI: 10.1016/j.amsu.2022.103832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 11/18/2022] Open
Abstract
Background Methods Results Conclusion CPR involves organized procedures performed on patients with cardiac arrest. CPR method and techniques can determine neurological outcomes of the patients. Glucocorticoid, methylprednisolone does not reduce the risk of neurological complications.
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Affiliation(s)
- Hooman Rafiei
- Department of Emergency Medicine, Faculty of Medicine, Kermanshah University of Medical Science, Kermanshah, Iran
- Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Nasrin Bahrami
- Student of Research Committee, Kermanshah University of Medical Science, Kermanshah, Iran
| | - Amir Hossein Meisami
- Department of Emergency Medicine, Faculty of Medicine, Kermanshah University of Medical Science, Kermanshah, Iran
| | - Haniyeh Azadifar
- Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shahrouz Tabrizi
- Department of Emergency Medicine, Faculty of Medicine, Kermanshah University of Medical Science, Kermanshah, Iran
- Corresponding author.
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Abdelazeem B, Awad AK, Manasrah N, Elbadawy MA, Ahmad S, Savarapu P, Abbas KS, Kunadi A. The Effect of Vasopressin and Methylprednisolone on Return of Spontaneous Circulation in Patients with In-Hospital Cardiac Arrest: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Am J Cardiovasc Drugs 2022; 22:523-533. [PMID: 35314927 DOI: 10.1007/s40256-022-00522-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Cardiac arrest is often fatal if not treated immediately by cardiopulmonary resuscitation to restore a normal heart rhythm and spontaneous circulation. We aim to evaluate the clinical benefits of vasopressin and methylprednisolone versus placebo for patients with in-hospital cardiac arrest. DATA SOURCES We searched PubMed, EMBASE, Scopus, Web of Science, Cochrane Central, and Google Scholar from inception to October 17, 2021, by using search terms included "Vasopressin" AND "Methylprednisolone" AND "Cardiac arrest". STUDY SELECTION AND DATA EXTRACTION We included randomized controlled trials (RCTs) that compared vasopressin and methylprednisolone to placebo. The main outcomes were the return of spontaneous circulation (ROSC) and survival to hospital discharge. DATA SYNTHESIS A total of three RCTs, with a total of 869 patients, were included. The pooled risk ratios (RRs) were calculated along with their 95% confidence intervals (CIs). Our result showed an increase in ROSC in patients who received vasopressin and methylprednisolone (RR = 1.32; 95% CI = [1.18, 1.47], p < 0.00001) when compared with the placebo group. However, there was no difference between both groups regarding survival to hospital discharge (RR = 1.76; 95% CI = [0.68, 4.56], p= 0.25). RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE The current guidelines recommend epinephrine for patients with in-hospital cardiac arrest. Our meta-analysis updates clinicians about using vasopressin and methylprednisolone besides epinephrine, providing them with the best available evidence in managing patients with in-hospital cardiac arrest. CONCLUSION Among patients with in-hospital cardiac arrest, administration of vasopressin and methylprednisolone besides epinephrine is associated with increased ROSC compared with placebo and epinephrine. However, high-quality RCTs are necessary before drawing a firm conclusion regarding the efficacy of vasopressin and methylprednisolone for patients with in-hospital cardiac arrest.
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Vandersmissen H, Gworek H, Dewolf P, Sabbe M. Drug use during adult advanced cardiac life support: An overview of reviews. Resusc Plus 2021; 7:100156. [PMID: 34430950 PMCID: PMC8371248 DOI: 10.1016/j.resplu.2021.100156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/14/2021] [Accepted: 07/17/2021] [Indexed: 01/08/2023] Open
Abstract
AIM To conduct an overview of systematic reviews and meta-analyses to summarize the ever-growing evidence on drug use during advanced life support. METHODS We searched Embase, Medline, Cochrane central register of controlled trials and Web of science for systematic reviews and meta-analyses reporting on drug use during advanced life support from inception to March, 2020. Two reviewers independently assessed all abstracts for eligibility, extracted data and assessed risk of bias using the AMSTAR-2 tool. Corrected covered areas were calculated from publication citation matrices to account for potential risk of bias. Data were graphically represented using forest plots. RESULTS Twenty-two head-to-head drug comparisons from 47 included articles were analysed. Adrenaline significantly increases the incidence of return of spontaneous circulation and survival to hospital discharge, but not the incidence of neurological intact survival. Vasopressin alone or in combination with adrenaline is not superior to adrenaline alone. There is a trend favouring lidocaine over amiodarone in shockable cardiac arrest. The risk of bias assessment of included studies ranged from very low to very high and the overlap between articles was moderate to high. CONCLUSIONS In line with the guidelines, we currently suggest that a standard dose of adrenaline should be administered during resuscitation, however, studies assessing lower doses of adrenaline are pressing. There is no rationale for the combination of vasopressin and adrenaline or vasopressin alone instead of adrenaline. In addition, lidocaine is a valuable alternative for amiodarone and maybe even preferable for shockable cardiac arrest. However more research is necessary.
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Affiliation(s)
- Hans Vandersmissen
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium
- KULeuven, Faculty of Medicine, Leuven, Belgium
| | - Hanne Gworek
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium
- KULeuven, Faculty of Medicine, Leuven, Belgium
| | - Philippe Dewolf
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium
- KULeuven, Department of Public Health and Primary Care, Leuven, Belgium
- KULeuven, Faculty of Medicine, Leuven, Belgium
| | - Marc Sabbe
- Department of Emergency Medicine, University Hospitals of Leuven, Leuven, Belgium
- KULeuven, Department of Public Health and Primary Care, Leuven, Belgium
- KULeuven, Faculty of Medicine, Leuven, Belgium
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7
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Srisurapanont K, Thepchinda T, Kwangsukstith S, Saetiao S, Kasirawat C, Janmayka W, Wongtanasarasin W. Comparing Drugs for Out-of-hospital, Shock-refractory Cardiac Arrest: Systematic Review and Network Meta-analysis of Randomized Controlled Trials. West J Emerg Med 2021; 22:834-841. [PMID: 35354019 PMCID: PMC8328185 DOI: 10.5811/westjem.2021.2.49590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 02/24/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The benefit of medications used in out-of-hospital, shock-refractory cardiac arrest remains controversial. This study aims to compare the treatment outcomes of medications for out-of-hospital, shock-refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT). METHODS The inclusion criteria were randomized controlled trials of participants older than eight years old who had atraumatic, out-of-hospital, shock-refractory VF/pVT in which at least one studied group received a medication. We conducted a database search on October 28, 2019, that included PubMed, Scopus, Web of Science, CINAHL Complete, and Cochrane CENTRAL. Citations of relevant meta-analyses were also searched. We performed frequentist network meta-analysis (NMA) to combine the comparisons. The outcomes were analyzed by using odds ratios (OR) and compared to placebo. The primary outcome was survival to hospital discharge. The secondary outcomes included the return of spontaneous circulation (ROSC), survival to hospital admission, and the neurological outcome at discharge. We ranked all outcomes using surface under the cumulative ranking score. RESULTS We included 18 studies with 6,582 participants. The NMA of 20 comparisons included 12 medications and placebo. Only norepinephrine showed a significant increase of ROSC (OR = 8.91, 95% confidence interval [CI], 1.88-42.29). Amiodarone significantly improved survival to hospital admission (OR = 1.53, 95% CI, 1.01-2.32). The ROSC and survival-to-hospital admission data were significantly heterogeneous with the I2 of 55.1% and 59.1%, respectively. This NMA satisfied the assumption of transitivity. CONCLUSION No medication was associated with improved survival to hospital discharge from out-of-hospital, shock-refractory cardiac arrest. For the secondary outcomes, norepinephrine was associated with improved ROSC and amiodarone was associated with an increased likelihood of survival to hospital admission in the NMA.
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Affiliation(s)
| | | | | | - Suchada Saetiao
- Chiang Mai University, Faculty of Medicine, Chiang Mai, Thailand
| | | | - Worawan Janmayka
- Chiang Mai University, Faculty of Medicine, Chiang Mai, Thailand
| | - Wachira Wongtanasarasin
- Chiang Mai University, Department of Emergency Medicine, Faculty of Medicine, Chiang Mai, Thailand
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8
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Wang MT, Huang WC, Yen DHT, Yeh EH, Wu SY, Liao HH. The Potential Risk Factors for Mortality in Patients After In-Hospital Cardiac Arrest: A Multicenter Study. Front Cardiovasc Med 2021; 8:630102. [PMID: 33796570 PMCID: PMC8007776 DOI: 10.3389/fcvm.2021.630102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 02/22/2021] [Indexed: 01/14/2023] Open
Abstract
Background and Purpose: In-hospital cardiac arrest (IHCA) has high mortality rate, which needs more research. This multi-center study aims to evaluate potential risk factors for mortality in patients after IHCA. Methods: Data for this study retrospectively enrolled IHCA patients from 14 regional hospitals, two district hospitals, and five medical centers between 2013 June and 2018 December. The study enrolled 5,306 patients and there were 2,871 patients in subgroup of intensive care unit (ICU) and emergency room (ER), and 1,894 patients in subgroup of general wards. Results: As for overall IHCA patients, odds ratio (OR) for mortality was higher in older patients (OR = 1.69; 95% CI:1.33–2.14), those treated with ventilator (OR = 1.79; 95% CI:1.36–2.38) and vasoactive agents (OR = 1.88; 95% CI:1.45–2.46). Whereas, better survival was reported in IHCA patients with initial rhythm as ventricular tachycardia (OR = 0.32; 95% CI: 0.21–0.50) and ventricular fibrillation (OR = 0.26; 95% CI: 0.16–0.42). With regard to ICU and ER subgroup, there was no mortality difference among different nursing shifts, whereas for patients in general wards, overnight shift (OR = 1.83; 95% CI: 1.07–3.11) leads to poor outcome. Conclusion: For IHCA patients, old age, receiving ventilator support and vasoactive agents reported poor survival. Overnight shift had poor survival for IHCA patients in general wards, despite no significance in overall and ICU/ER subgroups.
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Affiliation(s)
- Mei-Tzu Wang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Section of Cardiology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - David Hung-Tsang Yen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - En-Hui Yeh
- Joint Commission of Taiwan, New Taipei City, Taiwan
| | - Shih-Yuan Wu
- Joint Commission of Taiwan, New Taipei City, Taiwan
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9
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Biondi-Zoccai G, Cavarretta E, Frati G, Versaci F. Of Size and Men: A Call for Larger Trials and Meta-Analyses on Vasopressors During General Anesthesia. J Cardiothorac Vasc Anesth 2020; 35:70-72. [PMID: 33023817 PMCID: PMC7490586 DOI: 10.1053/j.jvca.2020.09.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Mediterranea Cardiocentro, Napoli, Italy.
| | - Elena Cavarretta
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Mediterranea Cardiocentro, Napoli, Italy
| | - Giacomo Frati
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; IRCCS NEUROMED, Pozzilli, Italy
| | - Francesco Versaci
- UOC UTIC, Emodinamica e Cardiologia, Ospedale S. Maria Goretti, Latina, Italy
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10
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Huan L, Qin F, Wu Y. Effects of epinephrine for out-of-hospital cardiac arrest: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2019; 98:e17502. [PMID: 31702610 PMCID: PMC6855610 DOI: 10.1097/md.0000000000017502] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
AIM Our objective is to assess the effects of epinephrine for out of hospital cardiac arrest. BACKGROUND Cardiac arrest was the most serious medical incidents with an estimated incidence in the United States of 95.7 per 100,000 person years. Though epinephrine improved coronary and cerebral perfusion, improving a return of spontaneous circulation, potentially harmful effects on the heart lead to greater myocardial oxygen demand. Concerns about the effect of epinephrine for out-of-hospital cardiac arrest were controversial and called for a higher argument to determine whether the effects of epinephrine is safe and effective for shor and long terms outcomes. METHOD Searching databases consist of all kinds of searching tools, such as Medline, the Cochrane Library, Embase, PubMed, etc. All the included studies should meet our demand of this meta-analysis. In the all interest outcomes blow we take the full advantage of STATA to assess, the main measure is Risk Ratio (RR) with 95% confidence, the publication bias are assessed by Egger Test. RESULT In current systematic review and meta-analysis of randomized trials investigating epinephrine for out of hospital cardiac arrest, we found that epinephrine was associated with a significantly higher likelihood of ROSC (RR = 3.05, I = 23.1%, P = .0001) and survival to hospital discharge (RR = 1.40, I = 36.3%, P = .008) compared with non-adrenaline administration. Conversely, epinephrine did not increase CPC 1 or 2 (RR = 1.15, I = 40.5%, P = .340) and hospital admission (RR = 2.07, I = 88.2%, P = .0001). CONCLUSION In conclusion, in this systematic review and meta-analysis involving studies, the use of epinephrine resulted in a significantly higher likelihood of survival to hospital discharge and ROSC than the non-epinephrine administration, but, there was no significant between group difference in the rate of a favorable neurologic outcome.
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Affiliation(s)
- Lu Huan
- Department of Hepatobiliary Surgery, Chongqing Fifth People's Hospital
| | - Fei Qin
- Department of Assisted Reproduction, The First Affiliated Hospital of Chongqing Medical University
| | - Yin Wu
- Department of Cardiovascular Medicine, Chongqing Construction Hospital, Chongqing, Chongqing, China
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Abstract
BACKGROUND Adrenaline and vasopressin are widely used to treat people with cardiac arrest, but there is uncertainty about the safety, effectiveness and the optimal dose. OBJECTIVES To determine whether adrenaline or vasopressin, or both, administered during cardiac arrest, afford any survival benefit. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase and DARE from their inception to 8 May 2018, and the International Liaison Committee on Resuscitation 2015 Advanced Life Support Consensus on Science and Treatment Recommendations. We also searched four trial registers on 5 September 2018 and checked the reference lists of the included studies and review papers to identify potential papers for review. SELECTION CRITERIA Any randomised controlled trial comparing: standard-dose adrenaline versus placebo; standard-dose adrenaline versus high-dose adrenaline; and adrenaline versus vasopressin, in any setting, due to any cause of cardiac arrest, in adults and children. There were no language restrictions. DATA COLLECTION AND ANALYSIS Two review authors independently identified trials for review, assessed risks of bias and extracted data, resolving disagreements through re-examination of the trial reports and by discussion. We used risk ratios (RRs) with 95% confidence intervals (CIs) to compare dichotomous outcomes for clinical events. There were no continuous outcomes reported. We examined groups of trials for heterogeneity. We report the quality of evidence for each outcome, using the GRADE approach. MAIN RESULTS We included 26 studies (21,704 participants).Moderate-quality evidence found that adrenaline increased survival to hospital discharge compared to placebo (RR 1.44, 95% CI 1.11 to 1.86; 2 studies, 8538 participants; an increase from 23 to 32 per 1000, 95% CI 25 to 42). We are uncertain about survival to hospital discharge for high-dose compared to standard-dose adrenaline (RR 1.10, 95% CI 0.75 to 1.62; participants = 6274; studies = 10); an increase from 33 to 36 per 1000, 95% CI 24 to 53); standard-dose adrenaline versus vasopressin (RR 1.25, 95% CI 0.84 to 1.85; 6 studies; 2511 participants; an increase from 72 to 90 per 1000, 95% CI 60 to 133); and standard-dose adrenaline versus vasopressin plus adrenaline (RR 0.76, 95% CI 0.47 to 1.22; 3 studies; 3242 participants; a possible decrease from 24 to 18 per 1000, 95% CI 11 to 29), due to very low-quality evidence.Moderate-quality evidence found that adrenaline compared with placebo increased survival to hospital admission (RR 2.51, 95% CI 1.67 to 3.76; 2 studies, 8489 participants; an increase from 83 to 209 per 1000, 95% CI 139 to 313). We are uncertain about survival to hospital admission when comparing standard-dose with high-dose adrenaline, due to very low-quality evidence. Vasopressin may improve survival to hospital admission when compared with standard-dose adrenaline (RR 1.27, 95% CI 1.04 to 1.54; 3 studies, 1953 participants; low-quality evidence; an increase from 260 to 330 per 1000, 95% CI 270 to 400), and may make little or no difference when compared to standard-dose adrenaline plus vasopressin (RR 0.95, 95% CI 0.83 to 1.08; 3 studies; 3249 participants; low-quality evidence; a decrease from 218 to 207 per 1000 (95% CI 181 to 236).There was no evidence that adrenaline (any dose) or vasopressin improved neurological outcomes.The rate of return of spontaneous circulation (ROSC) was higher for standard-dose adrenaline versus placebo (RR 2.86, 95% CI 2.21 to 3.71; participants = 8663; studies = 3); moderate-quality evidence; an increase from 115 to 329 per 1000, 95% CI 254 to 427). We are uncertain about the effect on ROSC for the comparison of standard-dose versus high-dose adrenaline and standard-does adrenaline compared to vasopressin, due to very low-quality evidence. Standard-dose adrenaline may make little or no difference to ROSC when compared to standard-dose adrenaline plus vasopressin (RR 0.97, 95% CI 0.87 to 1.08; 3 studies, 3249 participants; low-quality evidence; a possible decrease from 299 to 290 per 1000, 95% CI 260 to 323).The source of funding was not stated in 11 of the 26 studies. The study drugs were provided by the manufacturer in four of the 26 studies, but neither drug represents a profitable commercial option. The other 11 studies were funded by organisations such as research foundations and government funding bodies. AUTHORS' CONCLUSIONS This review provides moderate-quality evidence that standard-dose adrenaline compared to placebo improves return of spontaneous circulation, survival to hospital admission and survival to hospital discharge, but low-quality evidence that it did not affect survival with a favourable neurological outcome. Very low -quality evidence found that high-dose adrenaline compared to standard-dose adrenaline improved return of spontaneous circulation and survival to admission. Vasopressin compared to standard dose adrenaline improved survival to admission but not return of spontaneous circulation, whilst the combination of adrenaline and vasopressin compared with adrenaline alone had no effect on these outcomes. Neither standard dose adrenaline, high-dose adrenaline,vasopressin nor a combination of adrenaline and vasopressin improved survival with a favourable neurological outcome. Many of these studies were conducted more than 20 years ago. Treatment has changed in recent years, so the findings from older studies may not reflect current practice.
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Affiliation(s)
- Judith Finn
- Curtin UniversityPrehospital, Resuscitation and Emergency Care Research Unit (PRECRU)Kent StreetBentleyWestern AustraliaAustralia6102
- St John Ambulance Western AustraliaBelmontAustralia
| | - Ian Jacobs
- Curtin UniversityPrehospital, Resuscitation and Emergency Care Research Unit (PRECRU)Kent StreetBentleyWestern AustraliaAustralia6102
- St John Ambulance Western AustraliaBelmontAustralia
| | | | - Simon Gates
- University of BirminghamCancer Research UK Clinical Trials Unit, School of Cancer Sciences, Institute of Cancer and Genomic SciencesBirminghamUKB15 2TT
| | - Gavin D Perkins
- University of WarwickWarwick Medical School and University Hospitals BirminghamCoventryUK
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O'reilly M, Schmölzer GM. Evidence for vasopressors during cardiopulmonary resuscitation in newborn infants. Minerva Pediatr 2018; 71:159-173. [PMID: 30511562 DOI: 10.23736/s0026-4946.18.05452-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
An estimated 0.1% of term infants and up to 15% of preterm infants (2-3 million worldwide) need extensive resuscitation, defined as chest compression and 100% oxygen with or without epinephrine in the delivery room. Despite these interventions, infants receiving extensive resuscitation in the DR have a high incidence of mortality and neurologic morbidity. Successful resuscitation from neonatal cardiac arrest requires the delivery of high-quality chest compression using the most effective vasopressor with the optimal dose, timing, and route of administration during CPR. Current neonatal resuscitation guidelines recommend administration of epinephrine once CPR has started at a dose of 0.01-0.03 mg/kg preferably given intravenously, with repeated doses every 3-5 min until return of spontaneous circulation. This review examines the current evidence for epinephrine and alternative vasopressors during neonatal cardiopulmonary resuscitation.
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Affiliation(s)
- Megan O'reilly
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada.,Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Georg M Schmölzer
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada - .,Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
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