Vasopressin and epinephrine versus epinephrine in management of patients with cardiac arrest: a meta-analysis
1Department of Emergency The First Affiliated Hospital Sun Yat-Sen University
2Department of Organ Transplantation The First Affiliated Hospital of Sun Yat-Sen University
DOI: 10.22514/SV51.042010.3 Vol.5,Issue 1,April 2010 pp.20-26
Published: 27 April 2010
Objective. A combination of vasopressin and epinephrine may be more effective than epinephrine alone in cardiopulmonary resuscitation (CPR), but evidence is lacking to make clinical recommendations. This meta-analysis compares the efficacy of vasopressin and epinephrine used together versus epinephrine alone in cardiac arrest (CA).
Methods. We searched MEDLINE and EMBASE for randomized trials comparing the efficacy of vasopressin and epineph-rine versus epinephrine alone in adults with cardiac arrest. The primary outcome was the return of spontaneous circulation (ROSC) and the survival rate on admission and discharge .We also analyzed ROSC in subgroups of patients presenting with different arrest rhythms, such as asystole, pulseless electrical activity (PEA), ventricular fibrillation (VF).
Results. We analyzed 6 randomized trials out of 485 articles. We did not find evidence supporting the superiority of vasopres-sin and epinephrine used in combination, except for the survival rate at 24h 2.99 95% CI(1.43,6.28). No evidence supports the conclusion that vasopressin combined with epinephrine is better than epinephrine alone for ROSC, even amongst subgroups of patients.
Conclusion. This systematic review of the efficacy of vasopressin and epinephrine use found that its combined use is better for 24h survival rate but only in one study which included 122 patients. Further investigation will be needed to support the use of this combination for cardiac arrest management.
cardiopulmonary resus-citation, meta-analysis, epinephrine, vasopressin
XIAO-LI JING,DONG-PING WANG,XIN LI,HUI LI,XIAO-XING LIAO,YAN XIONG,XI-FU WANG . Vasopressin and epinephrine versus epinephrine in management of patients with cardiac arrest: a meta-analysis. Signa Vitae. 2010. 5(1);20-26.
1. Paradis NA, Koscove EM. Epinephrine in cardiac arrest: a critical review. Ann Emerg Med 1990 Nov;19(11):1288-301.
2. Barlow M. Vasopressin. Emerg Med (Fremantle ) 2002 Sep;14(3):304-14.
3. Garcia-Villalon AL, Garcia JL, Fernandez N, Monge L, Gomez B, Dieguez G. Regional differences in the arterial response to vasopressin: role of endothelial nitric oxide. Br J Pharmacol 1996 Aug;118(7):1848-54.
4. Wenzel V, Lindner KH, Krismer AC, Miller EA, Voelckel WG, Lingnau W. Repeated administration of vasopressin but not epinephrine maintains coronary perfusion pressure after early and late administration during prolonged cardiopulmonary resuscitation in pigs. Circu-lation 1999 Mar 16;99(10):1379-84.
5. Aung K, Htay T. Vasopressin for cardiac arrest: a systematic review and meta-analysis. Arch Intern Med 2005 Jan 10;165(1):17-24.
6. Lindner KH, Prengel AW, Brinkmann A, Strohmenger HU, Lindner IM, Lurie KG. Vasopressin administration in refractory cardiac arrest. Ann Intern Med 1996 Jun 15;124(12):1061-4.
7. 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 Jan 8;350(2):105-13.
8. Grmec S, Mally S. Vasopressin improves outcome in out-of-hospital cardiopulmonary resuscitation of ventricular fibrillation and pulseless ventricular tachycardia: a observational cohort study. Crit Care 2006 Feb;10(1):R13.
9. 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 Jul 14;358(9276):105-9.
10. 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 Feb 22;349(9051):535-7.
11. Callaway CW, Hostler D, Doshi AA, Pinchalk M, Roth RN, Lubin J, et al. Usefulness of vasopressin administered with epinephrine during out-of-hospital cardiac arrest. Am J Cardiol 2006 Nov 15;98(10):1316-21.
12. Gueugniaud PY, David JS, Chanzy E, Hubert H, Dubien PY, Mauriaucourt P, et al. Vasopressin and epinephrine vs. epinephrine alone in cardiopulmonary resuscitation. N Engl J Med 2008 Jul 3;359(1):21-30.
13. Ditchey RV, Lindenfeld J. Failure of epinephrine to improve the balance between myocardial oxygen supply and demand during closed-chest resuscitation in dogs. Circulation 1988 Aug;78(2):382-9.
14. Tang W, Weil MH, Sun S, Noc M, Yang L, Gazmuri RJ. Epinephrine increases the severity of postresuscitation myocardial dysfunction. Circulation 1995 Nov 15;92(10):3089-93.
15. Thrush DN, Downs JB, Smith RA. Is epinephrine contraindicated during cardiopulmonary resuscitation? Circulation 1997 Oct 21;96(8):2709-14.
16. Paradis NA, Wenzel V, Southall J. Pressor drugs in the treatment of cardiac arrest. Cardiol Clin 2002 Feb;20(1):61-78.
17. Wayne MA, Racht EM, Aghababian RV, Kudenchuk PJ, Ornato JP, Slovis CM. Prehospital management of cardiac arrest: how useful are vasopressor and antiarrhythmic drugs? Prehosp Emerg Care 2002 Jan;6(1):72-80.
18. Livesay JJ, Follette DM, Fey KH, Nelson RL, DeLand EC, Barnard RJ, et al. Optimizing myocardial supply/demand balance with alpha-adrenergic drugs during cardiopulmonary resuscitation. J Thorac Cardiovasc Surg 1978 Aug;76(2):244-51.
19. Midei MG, Sugiura S, Maughan WL, Sagawa K, Weisfeldt ML, Guerci AD. Preservation of ventricular function by treatment of ventricular fibrillation with phenylephrine. J Am Coll Cardiol 1990 Aug;16(2):489-94.
20. Lurie KG, Lindner KH. Recent advances in cardiopulmonary resuscitation. J Cardiovasc Electrophysiol 1997 May;8(5):584-600.
21. Nolan JP, Deakin CD, Soar J, Bottiger BW, Smith G. European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support. Resuscitation 2005 Dec;67 Suppl 1:S39-S86.
22. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005 Dec 13;112(24 Suppl):IV1-203.
23. Lindner KH, Prengel AW, Pfenninger EG, Lindner IM, Strohmenger HU, Georgieff M, et al. Vasopressin improves vital organ blood flow during closed-chest cardiopulmonary resuscitation in pigs. Circulation 1995 Jan 1;91(1):215-21.
24. Mulligan KA, McKnite SH, Lindner KH, Lindstrom PJ, Detloff B, Lurie KG. Synergistic effects of vasopressin plus epinephrine during car-diopulmonary resuscitation. Resuscitation 1997 Nov;35(3):265-71.
25. Lurie KG, Voelckel WG, Iskos DN, McKnite SH, Zielinski TM, Sugiyama A, et al. Combination drug therapy with vasopressin, adrenaline (epine-phrine) and nitroglycerin improves vital organ blood flow in a porcine model of ventricular fibrillation. Resuscitation 2002 Aug;54(2):187-94.
26. Mayr VD, Wenzel V, Voelckel WG, Krismer AC, Mueller T, Lurie KG, et al. Developing a vasopressor combination in a pig model of adult asphyxial cardiac arrest. Circulation 2001 Oct 2;104(14):1651-6.
27. Voelckel WG, Lurie KG, McKnite S, Zielinski T, Lindstrom P, Peterson C, et al. Effects of epinephrine and vasopressin in a piglet model of prolonged ventricular fibrillation and cardiopulmonary resuscitation. Crit Care Med 2002 May;30(5):957-62.
28. Guyette FX, Guimond GE, Hostler D, Callaway CW. Vasopressin administered with epinephrine is associated with a return of a pulse in out-of-hospital cardiac arrest. Resuscitation 2004 Dec;63(3):277-82.
29. Wenzel V, Linder KH, Augenstein S, Prengel AW, Strohmenger HU. Vasopressin combined with epinephrine decreases cerebral perfusion compared with vasopressin alone during cardiopulmonary resuscitation in pigs. Stroke 1998 Jul;29(7):1462-7.
30. Biondi-Zoccai GG, Abbate A, Parisi Q, Agostoni P, Burzotta F, Sandroni C, et al. Is vasopressin superior to adrenaline or placebo in the management of cardiac arrest? A meta-analysis. Resuscitation 2003 Nov;59(2):221-4.
31. Sillberg VA, Perry JJ, Stiell IG, Wells GA. Is the combination of vasopressin and epinephrine superior to repeated doses of epinephrine alone in the treatment of cardiac arrest-a systematic review. Resuscitation 2008 Dec;79(3):380-6.
32. Prengel AW, Lindner KH, Keller A. Cerebral oxygenation during cardiopulmonary resuscitation with epinephrine and vasopressin in pigs. Stroke 1996 Jul;27(7):1241-8.
33. Wenzel V, Lindner KH, Prengel AW, Maier C, Voelckel W, Lurie KG, et al. Vasopressin improves vital organ blood flow after prolonged cardiac arrest with postcountershock pulseless electrical activity in pigs. Crit Care Med 1999 Mar;27(3):486-92.
34. Wenzel V, Lindner KH, Krismer AC, Voelckel WG, Schocke MF, Hund W, et al. Survival with full neurologic recovery and no cerebral patho-logy after prolonged cardiopulmonary resuscitation with vasopressin in pigs. J Am Coll Cardiol 2000 Feb;35(2):527-33.
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