Vasopressin, steroids, and epinephrine improve in-hospital cardiac arrest survival


Clinical Question:
Does adding vasopressin and corticosteroids to epinephrine improve survival in patients with in-hospital cardiac arrest?

Bottom Line:
Adding vasopressin and a moderate dose of a corticosteroid to the advanced life support protocol, along with stress-dose steroids for postresuscitation shock, improves survival to hospital discharge in patients with refractory in-hospital cardiac arrest. Note that the overwhelming majority of survivors in the study group -- 8 of 9 patients -- were those who received stress-dose steroids; none of the patients in the control group with untreated postresuscitation shock survived. Future trials may need to focus on this intervention separately. (LOE = 1b)

Mentzelopoulos SD, Zakynthinos SG, Tzoufi M, et al. Vasopressin, epinephrine, and corticosteroids for in-hospital cardiac arrest. Arch Intern Med 2009;169(1):15-24.  [PMID:19139319]

Study Design:
Randomized controlled trial (double-blinded)



Inpatient (any location)

Investigators in a tertiary care teaching hospital randomized, using concealed allocation, 100 consecutive patients with refractory in-hospital arrest to receive either typical doses of epinephrine (1 mg) or epinephrine in combination with vasopressin 20 IU during each of the first 5 CPR cycles following entry into the study. The study group also received methylprednisolone 40 mg during the first cycle, followed by stress doses of hydrocortisone for those with postresuscitation shock. The primary outcomes (ie, return of spontaneous circulation for more than 15 minutes and survival to hospital discharge) were significantly higher in the study group. A total of 81% in the study group had return of spontaneous circulation for more than 15 minutes, as compared with 52% of the control group (P =.003; number needed to treat [NNT] = 4). More important, those in the study group were more likely to survive to discharge (19% vs 4%) with 1 additional patient being alive at discharge for every 7 patients treated with the combination rather than epinephrine alone (NNT = 7). Patients with postresuscitation shock who received stress doses of a corticosteroid also had higher rates of survival to hospital discharge (30% vs 0%).

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