Effects of thrombolysis during out-of-hospital cardiopulmonary resuscitation.

In this post hoc analysis, we assessed effects of thrombolysis during out-of-hospital cardiopulmonary resuscitation. The original study was designed as a double-blinded, prospective, multicenter, randomized, controlled clinical trial. In this report, 1,219 patients were randomized, but 33 patients were excluded due to missing study drug codes. Thus, 1,186 patients were analyzed based on receipt (n = 99) versus nonreceipt (n = 1,087) of thrombolysis; the primary end point was hospital admission, and the secondary end point was hospital discharge. Patients who received thrombolysis versus those who did not were significantly younger (mean +/- SD 62.7 +/- 13.3 vs 66.5 +/- 14.3 years of age, p = 0.01) and more likely to have had an acute myocardial infarction (75.3% vs 54.6%, p < 0.01) or pulmonary embolism (20.2% vs 12.0%, p = 0.03) as the suspected underlying cause for cardiac arrest. In patients who underwent thrombolysis versus those who did not, cardiac arrest was more often witnessed (86.9% vs 77.5%, p = 0.03), initial ventricular fibrillation was more likely (59.6% vs 38.0%, p < 0.01), and a short estimated interval (0 to 5 minutes) between collapse and initiation of basic life support was more likely (51.3% vs 29.2%, p < 0.01). In patients who received thrombolysis, sodium bicarbonate (45.5% vs 33.0%, p = 0.01), lidocaine (32.3% vs 18.1%, p < 0.01), and amiodarone (30.3% vs 12.2%, p < 0.01) were administered significantly more often. Hospital admission rates were significantly higher in patients who underwent thrombolysis than in patients who did not (45.5% vs 32.7%, p = 0.01), and there was a trend to higher hospital discharge rates (14.1% vs 9.5%, p = 0.14). In patients who had suspected myocardial infarction, hospital admission and discharge rates were significantly higher in patients who underwent thrombolysis than in patients who did not. In logistic regression models after adjusting for confounding variables (e.g., age, initial electrocardiographic rhythm, and initiation of basic life support), hospital admission and discharge rates did not differ significantly. In conclusion, even when being employed in patients with a potentially better chance to survive, thrombolysis in patients with cardiac arrest resulted in an increased hospital admission but not discharge rate in this post hoc analysis.

Vasopressin during cardiopulmonary resuscitation: a progress report.

OBJECTIVE: In patients undergoing cardiopulmonary resuscitation, circulating endogenous vasopressin concentrations were significantly higher in successfully resuscitated patients than in patients who died. These observations have prompted several investigations to assess the role of vasopressin to improve cardiopulmonary resuscitation management. DESIGN: Literature review. RESULTS: In the cardiopulmonary resuscitation laboratory, vasopressin improved vital organ blood flow, cerebral oxygen delivery, the probability of restoring spontaneous circulation, and neurologic recovery better than epinephrine. In pediatric preparations with asphyxia, epinephrine was superior to vasopressin, whereas in both pediatric pigs with ventricular fibrillation and adult porcine models with asphyxia, combinations of vasopressin and epinephrine proved to be highly effective. In addition, vasopressin enabled short- and long-term survival in a porcine model of uncontrolled hemorrhagic shock. In a recently published European, multiple-center trial, 1,219 adult patients with out-of-hospital cardiac arrest were randomized to receive two injections of either 40 IU of vasopressin or 1 mg of epinephrine followed by additional epinephrine if needed. The clinical study did not confirm laboratory data showing vasopressin to be more effective than epinephrine in ventricular fibrillation and pulseless electrical activity, but vasopressin was superior to epinephrine in patients with asystole. Vasopressin followed by epinephrine was more effective than epinephrine alone in the treatment of refractory cardiac arrest. CONCLUSIONS: According to new data from the European vasopressin study, we suggest, first, the administration of 1 mg of epinephrine, followed alternately by 40 IU of vasopressin and 1 mg of epinephrine every 3 mins in adult cardiac arrest victims, regardless of the initial electrocardiographic rhythm.

A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation.

BACKGROUND: Vasopressin is an alternative to epinephrine for vasopressor therapy during cardiopulmonary resuscitation, but clinical experience with this treatment has been limited. METHODS: We randomly assigned adults who had had an out-of-hospital cardiac arrest to receive two injections of either 40 IU of vasopressin or 1 mg of epinephrine, followed by additional treatment with epinephrine if needed. The primary end point was survival to hospital admission, and the secondary end point was survival to hospital discharge. RESULTS: A total of 1219 patients underwent randomization; 33 were excluded because of missing study-drug codes. Among the remaining 1186 patients, 589 were assigned to receive vasopressin and 597 to receive epinephrine. The two treatment groups had similar clinical profiles. There were no significant differences in the rates of hospital admission between the vasopressin group and the epinephrine group either among patients with ventricular fibrillation (46.2 percent vs. 43.0 percent, P=0.48) or among those with pulseless electrical activity (33.7 percent vs. 30.5 percent, P=0.65). Among patients with asystole, however, vasopressin use was associated with significantly higher rates of hospital admission (29.0 percent, vs. 20.3 percent in the epinephrine group; P=0.02) and hospital discharge (4.7 percent vs. 1.5 percent, P=0.04). Among 732 patients in whom spontaneous circulation was not restored with the two injections of the study drug, additional treatment with epinephrine resulted in significant improvement in the rates of survival to hospital admission and hospital discharge in the vasopressin group, but not in the epinephrine group (hospital admission rate, 25.7 percent vs. 16.4 percent; P=0.002; hospital discharge rate, 6.2 percent vs. 1.7 percent; P=0.002). Cerebral performance was similar in the two groups. CONCLUSIONS: The effects of vasopressin were similar to those of epinephrine in the management of ventricular fibrillation and pulseless electrical activity, but vasopressin was superior to epinephrine in patients with asystole. Vasopressin followed by epinephrine may be more effective than epinephrine alone in the treatment of refractory cardiac arrest.