Download Vasopressin Trial (ACLS)

Vasopressin verses epinephrine for inhospital cardiac arrest:
a randomized controlled trial
Lancet 2001;358:105-9 (July 14)
Study Type: POEM
Purpose: Are survival outcomes greater when vasopressin is used as first line treatment for cardiac arrest verses epinephrine?
Study Duration: 15 month enrollment, 324 assessed, 200 randomized, 124 excluded
Trial Design: triple-blinded, randomized, multicenter (3 sites, 2 tertiary-care hospitals in Canada and 1 in England)
Drug: patient got either vasopressin 40 units or epinephrine 1 mg, if patient failed initial dose of unknown drug, standard doses of epinephrine were
given every 3-5 min
Patients: age = 70 +/-12; 63% male; 81% had witness arrest; 18% ventricular fibrillation; 35% had ischemia or MI as cause; vasopressin was more
likely to be given on the floor than in the unit or ED as compared to epi;
Inclusion: admitted to hospital with cardiac arrest, requires epinephrine according to AHA ACLS protocols,
Exclusion: younger than 16 years, documented terminal illness, DNR status, trauma admission < 24 hours, arrest due to obvious aortic aneurysm,
massive GI bleed, arrest before hospitalization, cardiac arrest in the OR or RR
Outcome Events: Primary endpoint: continuous presence of a measurable pulse and blood pressure for at least one hour from the time of
resuscitation was discontinued
Secondary Outcomes: survival to hospital discharge, , MMSE, five-point scale for cerebral performance, adverse events
1.
a.
b.
c.
d.
Are the results valid?
randomized? yes
were groups similar? yes, but no statistics
double-blinded? yes
all patients accounted for? yes
2.
What were the results?
Time to treatment (mean)
Primary Outcomes
Survival at 1 hour
hospital discharge
Secondary Outcomes
any return of pulse
pulse > 20 min
24 h survival
30 day survival
Adverse Effects
tachyarrhythmias
hypertension
mesenteric infarction
3.
*
*
*
*
*
*
*
Collapse to CPR
ACLS treatment
study drug
1.6 min
2.8 min
6.1 min
Vasopressin
39%
12%
Epinephrine
35%
14%
ARR
4%
-2%
NNT
n/a
n/a
p-value
0.66
0.67
60%
43%
26%
13%
59%
40%
24%
14%
1%
3%
2%
-1%
n/a
n/a
n/a
n/a
0.97
0.60
0.74
0.83
10%
0
0
8%
0
0
2%
n/a
0.75
Will the results help me?
no difference between treatment for short or long-term survival
subgroup analysis - vasopressin offered NO improved outcomes (i.e., age differences, the reason for the cardiac arrest or type of
initial rhythm)
no difference in MMSE with survivors
ACLS guideline changes are based on a series of case reports that show improved outcomes with vasopressin. Case reports are very
weak data.
There is one randomized-controlled trial that offers improved outcomes with vasopressin in the out-of-hospital patient.
All of these studies are underpowered, but this study has the greatest number of patients so far.
The authors disagree with the AHA in recommending the ACLS guideline changes.
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