Vasopressin improves outcome in out-of-hospital cardiopulmonary resuscitation of ventricular fibrillation and pulseless ventricular tachycardia: a observational cohort study

Vasopressin improves outcome in out-of-hospital cardiopulmonary resuscitation of ventricular fibrillation and pulseless ventricular tachycardia: a observational cohort study

Stefan Mally, Stefek Grmec
PubMed
Published: May 2008
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An increasing body of evidence from laboratory and clinical studies suggests that vasopressin may represent a promising alternative vasopressor for use during cardiac arrest and resuscitation. Current guidelines for cardiopulmonary resuscitation recommend the use of adrenaline (epinephrine), with vasopressin considered only as a secondary option because of limited clinical data.

Method
The present study was conducted in a prehospital setting and included patients with ventricular fibrillation or pulseless ventricular tachycardia undergoing one of three treatments: group I patients received only adrenaline 1 mg every 3 minutes; group II patients received one intravenous dose of arginine vasopressine (40 IU) after three doses of 1 mg epinephrine; and patients in group III received vasopressin 40 IU as first-line therapy. The cause of cardiac arrest (myocardial infarction or other cause) was established for each patient in hospital.

Results
A total of 109 patients who suffered nontraumatic cardiac arrest were included in the study. The rates of restoration of spontaneous circulation and subsequent hospital admission were higher in vasopressin-treated groups (23/53 [45%] in group I, 19/31 [61%] in group II and 17/27 [63%] in group III). There were also higher 24-hour survival rates among vasopressin-treated patients (P < 0.05), and more vasopressin-treated patients were discharged from hospital (10/51 [20%] in group I, 8/31 [26%] in group II and 7/27 [26%] group III; P = 0.21). Especially in the subgroup of patients with myocardial infarction as the underlying cause of cardiac arrest, the hospital discharge rate was significantly higher in vasopressin-treated patients (P < 0.05). Among patients who were discharged from hospital, we found no significant differences in neurological status between groups.

Conclusion
The greater 24-hour survival rate in vasopressin-treated patients suggests that consideration of combined vasopressin and adrenaline is warranted for the treatment of refractory ventricular fibrillation or pulseless ventricular tachycardia. This is especially the case for those patients with myocardial infarction, for whom vasopressin treatment is also associated with a higher hospital discharge rate.

Introduction
Survival after cardiopulmonary resuscitation (CPR) with adrenaline (epinephrine) therapy is disappointing 1,2. The use of adrenaline is associated with increased myocardial oxygen consumption, ventricular arrhythmias and myocardial dysfunction during the period following resuscitation 3-5. In the American Heart Association 2000 Guidelines and in the Emergency Cardiovascular Care Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, vasopressin is considered a secondary alternative to adrenaline in the treatment of unstable ventricular tachycardia (VT) and ventricular fibrillation (VF)6,7. During CPR it significantly improves total cerebral and left myocardial blood flow, and it causes a sustained increase in mean arterial blood pressure as compared with maximal doses of adrenaline 8-14. However, some clinical studies yielded contrasting findings 15-19. Moreover, clinical experience with vasopressin as an alternative to adrenaline for vasopressor therapy in CPR is limited 6,7,20-25.

We conducted a clinical investigation to assess the effect of vasopressin on outcome in out-of-hospital CPR for VF and pulseless VT. Our hypothesis was that vasopressin improves outcome in VF/VT cardiac arrest, especially in patients with acute myocardial infarction (AMI).

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