Vasopressin for cardiac arrest increases chances of survival
http://www.100md.com
《英国医生杂志》
New York
People with refractory cardiac arrest are three times as likely to survive if they are given the antidiuretic hormone vasopressin than if they receive the standard emergency treatment, adrenaline (epinephrine).
The new findings are from a study of patients with cardiac arrest in Austria, Germany, and Switzerland.
The current international guidelines for coronary pulmonary resuscitation recommend the use of adrenaline during cardiac resuscitation and consider vasopressin only as a secondary alternative, because clinical data on treatment with vasopressin have been limited.
Researchers led by Volker Wenzel of the department of anaesthesiology and critical care medicine at Leopold-Franzens University, Innsbruck, Austria, randomly assigned adults who had had an out of hospital cardiac arrest to have two injections of either 40 IU of vasopressin or 1 mg of adrenaline, followed by additional treatment with adrenaline if needed. The primary end point was survival to hospital admission, and the secondary end point was survival to hospital discharge ( New England Journal of Medicine 2004;350: 105-13).
A total of 1186 patients took part in the study: 589 were assigned to receive vasopressin and 597 to receive adrenaline. The two treatment groups had similar clinical profiles.
Among patients with ventricular fibrillation there was no significant difference between the two groups in the percentage of patients who survived to be admitted to hospital (46.2% of patients in the vasopressin group and 43.0% in the adrenaline group; odds ratio 0.9 (95% confidence interval 0.6 to 1.3). Neither was there a difference among patients with pulseless electrical activity (33.7% and 30.5%; odds ratio 0.8 (0.5 to 1.6)).
Among patients with asystole, however, the percentage of patients admitted to hospital was higher in the vasopressin group (29.0%) than in the adrenaline group (20.3%) (odds ratio 0.6 (0.4 to 0.9)). The percentage of patients who survived to discharge was also higher in the vasopressin group (4.7% versus 1.5%; odds ratio 0.3 (0.1 to 1.0)).
Moreover, among the 732 patients in whom spontaneous circulation was not restored with the two injections of the study drug, additional treatment with adrenaline led to a higher proportion of patients surviving to hospital admission and hospital discharge in the vasopressin group than in the adrenaline group (hospital admission: 25.7% versus 16.4%; hospital discharge: 6.2% versus 1.7%).
Adrenaline has been used in cardiac pulmonary resuscitation for more than 100 years but has become controversial because it is associated with increased myocardial oxygen consumption, ventricular arrhythmias, and myocardial dysfunction in the period after resuscitation.
Because of the discovery that endogenous vasopressin concentrations were significantly higher in successfully resuscitated patients than in patients who died, it was postulated that administering vasopressin during coronary pulmonary resuscitation might be a benefit.
Laboratory studies showed that vasopressin was associated with better blood flow to vital organs, delivery of cerebral oxygen, chances of resuscitation, and neurological outcomes, compared with adrenaline. But this is the first large scale clinical study to show significant benefits from the use of vasopressin.
Dr Wenzel said he had already changed the way he treated patients. Now he gives nearly all adults with cardiac arrest both vasopressin and adrenaline. "Get it in there, bang bang, and you either save a life immediately or you don't," he said.(Scott Gottlieb)
People with refractory cardiac arrest are three times as likely to survive if they are given the antidiuretic hormone vasopressin than if they receive the standard emergency treatment, adrenaline (epinephrine).
The new findings are from a study of patients with cardiac arrest in Austria, Germany, and Switzerland.
The current international guidelines for coronary pulmonary resuscitation recommend the use of adrenaline during cardiac resuscitation and consider vasopressin only as a secondary alternative, because clinical data on treatment with vasopressin have been limited.
Researchers led by Volker Wenzel of the department of anaesthesiology and critical care medicine at Leopold-Franzens University, Innsbruck, Austria, randomly assigned adults who had had an out of hospital cardiac arrest to have two injections of either 40 IU of vasopressin or 1 mg of adrenaline, followed by additional treatment with adrenaline if needed. The primary end point was survival to hospital admission, and the secondary end point was survival to hospital discharge ( New England Journal of Medicine 2004;350: 105-13).
A total of 1186 patients took part in the study: 589 were assigned to receive vasopressin and 597 to receive adrenaline. The two treatment groups had similar clinical profiles.
Among patients with ventricular fibrillation there was no significant difference between the two groups in the percentage of patients who survived to be admitted to hospital (46.2% of patients in the vasopressin group and 43.0% in the adrenaline group; odds ratio 0.9 (95% confidence interval 0.6 to 1.3). Neither was there a difference among patients with pulseless electrical activity (33.7% and 30.5%; odds ratio 0.8 (0.5 to 1.6)).
Among patients with asystole, however, the percentage of patients admitted to hospital was higher in the vasopressin group (29.0%) than in the adrenaline group (20.3%) (odds ratio 0.6 (0.4 to 0.9)). The percentage of patients who survived to discharge was also higher in the vasopressin group (4.7% versus 1.5%; odds ratio 0.3 (0.1 to 1.0)).
Moreover, among the 732 patients in whom spontaneous circulation was not restored with the two injections of the study drug, additional treatment with adrenaline led to a higher proportion of patients surviving to hospital admission and hospital discharge in the vasopressin group than in the adrenaline group (hospital admission: 25.7% versus 16.4%; hospital discharge: 6.2% versus 1.7%).
Adrenaline has been used in cardiac pulmonary resuscitation for more than 100 years but has become controversial because it is associated with increased myocardial oxygen consumption, ventricular arrhythmias, and myocardial dysfunction in the period after resuscitation.
Because of the discovery that endogenous vasopressin concentrations were significantly higher in successfully resuscitated patients than in patients who died, it was postulated that administering vasopressin during coronary pulmonary resuscitation might be a benefit.
Laboratory studies showed that vasopressin was associated with better blood flow to vital organs, delivery of cerebral oxygen, chances of resuscitation, and neurological outcomes, compared with adrenaline. But this is the first large scale clinical study to show significant benefits from the use of vasopressin.
Dr Wenzel said he had already changed the way he treated patients. Now he gives nearly all adults with cardiac arrest both vasopressin and adrenaline. "Get it in there, bang bang, and you either save a life immediately or you don't," he said.(Scott Gottlieb)