Vasopressin and epinephrine vs. epinephrine alone in cardiopulmonary resuscitation.

BACKGROUND: During the administration of advanced cardiac life support for resuscitation from cardiac arrest, a combination of vasopressin and epinephrine may be more effective than epinephrine or vasopressin alone, but evidence is insufficient to make clinical recommendations. METHODS: In a multicenter study, we randomly assigned adults with out-of-hospital cardiac arrest to receive successive injections of either 1 mg of epinephrine and 40 IU of vasopressin or 1 mg of epinephrine and saline placebo, followed by administration of the same combination of study drugs if spontaneous circulation was not restored and subsequently by additional epinephrine if needed. The primary end point was survival to hospital admission; the secondary end points were return of spontaneous circulation, survival to hospital discharge, good neurologic recovery, and 1-year survival. RESULTS: A total of 1442 patients were assigned to receive a combination of epinephrine and vasopressin, and 1452 to receive epinephrine alone. The treatment groups had similar baseline characteristics except that there were more men in the group receiving combination therapy than in the group receiving epinephrine alone (P=0.03). There were no significant differences between the combination-therapy and the epinephrine-only groups in survival to hospital admission (20.7% vs. 21.3%; relative risk of death, 1.01; 95% confidence interval [CI], 0.97 to 1.05), return of spontaneous circulation (28.6% vs. 29.5%; relative risk, 1.01; 95% CI, 0.97 to 1.06), survival to hospital discharge (1.7% vs. 2.3%; relative risk, 1.01; 95% CI, 1.00 to 1.02), 1-year survival (1.3% vs. 2.1%; relative risk, 1.01; 95% CI, 1.00 to 1.02), or good neurologic recovery at hospital discharge (37.5% vs. 51.5%; relative risk, 1.29; 95% CI, 0.81 to 2.06). CONCLUSIONS: As compared with epinephrine alone, the combination of vasopressin and epinephrine during advanced cardiac life support for out-of-hospital cardiac arrest does not improve outcome. (ClinicalTrials.gov number, NCT00127907.)

Constant flow insufflation of oxygen as the sole mode of ventilation during out-of-hospital cardiac arrest.

BACKGROUND: Constant flow insufflation of oxygen (CFIO) through a Boussignac multichannel endotracheal tube has been reported to be an efficient ventilatory method during chest massage for cardiac arrest. METHODS: Patients resuscitated for out-of-hospital cardiac arrest were randomly assigned to standard endotracheal intubation and mechanical ventilation (MV; n =457) or use of CFIO at a flow rate of 15 l/min (n=487). Continuous chest compressions were similar in the two groups. Pulse oximetry level was recorded every 5[Symbol: see text]min. Outcome of initial resuscitation, hospital admission, complications, and discharge from the intensive care unit (ICU) were analyzed. The randomization scheme was changed during the study, but the in-depth analysis was performed only on the first cohort of 341 patients with CFIO and 355 with MV, because of randomization problems in the second part. RESULTS: No difference in outcome was noted regarding return to spontaneous circulation (CFIO 21%, MV 20%), hospital admission (CFIO 17%, MV 16%), or ICU discharge (CFIO 2.4%, MV 2.3%). The level of detectable pulse saturation and the proportion of patients with saturation above 70% were higher with CFIO. Ten patients with MV but only one with CFIO had rib fractures. CONCLUSIONS: CFIO is a simplified alternative to MV, with favorable effects regarding oxygenation and fewer complications, as observed in this group of patients with desperate prognosis.