vasopressin vs epinephrine

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DGReview

Preference For Vasopressin Over Epinephrine Challenged

A DGReview of : " Vasopressin versus epinephrine for inhospital cardiac arrest: a

randomised controlled trial "

Lancet

07/13/2001

By Harvey McConnell

No survival advantage for vasopressin over epinephrine for hospital cardiac

arrest patients has been demonstrated in a trial finding with significant

international implications.

" We employed a strictly blinded and rigorously controlled design that

incorporated a typical in-hospital mix of cardiac arrest patients in three large

tertiary-care hospitals, " declares Dr. Ian G. Stiell, Clinical Epidemiology

Unit, Ottawa Health Research Institute, Ottawa, Ontario, Canada.

However, he and colleagues at the University of Ottawa and University of

Alberta, in Edmonton, Alberta, Canada, " failed to detect even a modest trend

favoring vasopressin, even in the pure subgroups of myocardial ischaemia or

infarction, or ventricular fibrillation or tachycardia. "

As a result of the triple-blind randomized trial, the clinicians " strongly

disagree " with the American Heart Association (AHA) Advanced Cardiac Life

Support (ACLS) guidelines, which recommend vasopressin as an alternative to

epinephrine for treatment of cardiac arrest.

Dr. Stiell points out that there are an estimated 300,000 cardiac arrests yearly

in hospitals throughout Canada and the United States.

In an earlier trial, he and his colleagues found that the survival rate of

hospital patients who required epinephrine was only six percent. Research by

others in the out-of-hospital setting suggested better outcomes for patients

treated with vasopressin than for those given epinephrine.

The current study by Dr. Stiell and colleagues was carried out in the emergency

departments, critical care units and wards of three Canadian teaching hospitals.

One hundred and four adults who had cardiac arrest and required drug therapy

received one dose of vasopressin 40 U and 96 patients received epinephrine 1 mg

intravenously as the initial vasopressor. Patients who failed to respond to the

study intervention were given epinephrine as a rescue medication.

Primary outcomes were survival to hospital discharge, survival to one hour and

neurological function. Preplanned subgroup assessments included patients with

myocardial ischaemia or infarction, initial cardiac rhythm, and age.

Clinicians found that for patients receiving vasopressin or epinephrine,

survival did not differ for hospital discharge, or for one-hour survival.

Survivors had closely similar median mini-mental state examination scores and

median cerebral performance category scores.

" We failed to show any improvement with vasopressin compared with epinephrine

for either short-term or long-term survival, " Dr. Stiell and colleagues declare.

" Furthermore, in several clinically important subgroups, vasopressin was not

associated with improved outcomes.

" We recognize that, because of our small sample size and the wide confidence

intervals around the treatment effect estimates, our results do not exclude the

possibility of a clinically important benefit for vasopressin. Nevertheless, we

detected no trends favoring vasopressin and suspect that the magnitude of any

potential benefit would be small if present at all. "

The clinicians conclude: " We strongly disagree with the decision of the AHA to

recommend vasopressin as an alternative to epinephrine. Their ACLS guidelines

are used worldwide and will affect the care of millions of patients with cardiac

arrest both inside and outside of hospital.

" We believe that vasopressin cannot be recommended unless further larger

clinical trials show evidence of improved survival to hospital discharge. "

Lancet 2001; 358: 105-09. " Vasopressin versus epinephrine for inhospital cardiac

arrest: a randomised controlled trial "

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