A recently published study in the New England Journal of Medicine, and an accompanying editorial have thrown down the gauntlet to those organisations that produce guidelines for cardiac arrest management. In this large European study, the investigators evaluated the potential role of vasopressin as the initial vasopressor in the management of out-of-hospital cardiac arrests. Two doses of either vasopressin (40 Units) or adrenaline (1 mg) were administered to patients who required vasopressor support (in accord with European Resuscitation Council guidelines). Across the board, there were no differences in rates of hospital admission or hospital discharge but two post-hoc observations did however raise some interesting points. Firstly, there was a small but significant increase in the hospital discharge rates with vasopressin when the initial cardiac rhythm was asystole. Secondly, the benefits associated with vasopressin seemed to be associated with patients who did not respond to vasopressin alone, but required additional management with adrenaline.

This study was performed in a pre-hospital setting with physician–staffed emergency medical service units. The time intervals to administration of drugs were long (mean of 8 minutes of untreated [no BLS] cardiac arrest, then 10 minutes more until administration of first dose of study drug). There were some disturbing trends towards increased likelihood of adverse neurological outcomes (eg. coma, and severe cerebral disability) in the survivors from the vasopressor group, and this study contradicts the earlier out-of-hospital study of ventricular fibrillation that found dramatically improved short-term survival advantage with a single dose (40 Units) vasopressin.

The ARC is in the process of completing an evidence-based review, but at this stage no change in management or algorithms are required.

Further reading:

  1. Lindner KH, Dirks B, Strohmenger HU, Prengel AW, Lindner IM, Lurie KG. Randomised comparison of epinephrine and vasopressin in patients with out-of-hospital ventricular fibrillation. Lancet 1997;349(9051):535-7.
  2. Stiell IG, Hebert PC, Wells GA, Vandemheen KL, Tang AS, Higginson LA, et al. Vasopressin versus epinephrine for inhospital cardiac arrest: a randomised controlled trial. Lancet 2001;358(9276):105-9.
  3. Wenzel V, Krismer AC, Arntz HR, Sitter H, Stadlbauer KH, Lindner KH. A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med 2004;350(2):105-13.
  4. McIntyre KM. Vasopressin in asystolic cardiac arrest. N Engl J Med 2004;350(2):179-81.

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