Vasopressin or adrenaline in cardiac resuscitation
Date First Published:
February 21, 2002
Last Updated:
January 21, 2004
Report by:
Kerstin Hogg, Clinical Research Fellow (Manchester Royal Infirmary)
Search checked by:
Reddy Mahu and Ian Crawford, Manchester Royal Infirmary
Three-Part Question:
In [cardiac resuscitation] is [vasopressin more effective than adrenaline] at achieving [return of spontaneous circulation and longterm survival]?
Clinical Scenario:
A 67 year old man has been brought into the emergency department by paramedic ambulance. He was initially in ventricular fibrillation, but now has pulseless electrical activity. He collapsed 15 minutes ago and received immediate bystander basic life support. You wonder whether intravenous vasopressin would be better than adrenaline in this situation.
Search Strategy:
Medline 1966-01/04 using the OVID interface.
Search Details:
[(exp vasopressins OR vasopressin.mp OR ADH.mp OR antidiuretic hormone.mp) AND (exp epinephrine OR epinephrine.mp OR adrenaline.mp) AND (exp resuscitation OR exp cardiopulmonary resuscitation OR exp Heart arrest OR arrest.mp OR exp ventricular fibrillation OR VF.mp OR ventricular fibrillation.mp OR asystole.mp OR EMD.mp OR electromechanical dissociation.mp OR PEA.mp OR pulseless electrical activity.mp)] LIMIT to human AND English.
Outcome:
Altogether 47 papers were found, only 3 papers compared the effects of adrenaline and vasopressin.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Randomised comparison of epinephrine and vasopressin in patients with out-of-hospital ventricular fibrillation. Lindner KH, Dirks B, Strohmenger H, et al. 1997, Germany | 40 pre-hospital VF arrests Randomised to receive either initial dose vasopressin (40u) or adrenaline (1mg) |
Prospective randomised double-blind trial | GCS on discharge | 10.7 adrenaline vs 11.7 vasopressin | Only looked at VF Small patient sample All out of hospital arrests with mean emergency team response times of 6 minutes |
| Spontaneous circulation on admission to hospital | 35% adrenaline vs 70% vasopressin (p=0.06) | ||||
| Survival to discharge | 15 % adrenaline vs 40 % vasopressin (p=0.16) | ||||
| 24 hour survival | 20% adrenaline vs 60 % vasopressin (p=0.02) | ||||
| Restoration of spontaneous circulation | 55% Adrenaline vs 80% vasopressin patients (p=0.18) | ||||
| Vasopressin versus epinephrine for inhospital cardiac arrest: a randomised controlled trial. Stiell IG, Hebert PC, Wells GA, et al. 2001, Canada | 200 patients treated for cardiac arrest in three hospitals. Randomised to receive either initial dose vasopressin (40U) or adrenaline (1mg). |
Prospective randomised double-blind trial | Survival to discharge | Vasopressin 12%, adrenaline 14% | Powered only to show a 20% difference in 1 hour survival |
| Presence of pulse and BP for one hour post resuscitation | Vasopressin group 39% Adrenaline group 35%(not significant) | ||||
| Neurological function at discharge | No difference between groups | ||||
| 30 day survival | No difference between groups | ||||
| A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. Wenzel V, Krismer A, Arntz R, et al. 2004, European resuscitation council | 589 patients with out-of-hospital cardiac arrest randomised to receive 40IU IV vasopressin x 2 and 597 patients randomised to receive 1mg adrenaline IV. Conducted in three countries | RCT | Restoration of circulation | No significant difference | 4748 out of 5967 patients with out-of-hospital cardiac arrest were not randomised The study was powered to show a 25% improvement in outcome. Evidence of a smaller benefit would require a much larger study |
| Survival to hospital | No significant difference | ||||
| Survival to discharge from hospital | No significant difference | ||||
| When subgroups analysed, significantly more patients in asystole survived to hospital 76/262 vs 54/266<br>p = 0.02 after vasopressin administration. The difference in survival to discharge was not statistically significant<br>Of those who went on to require additional adrenaline doses, all three outcomes were better in the vasopressin group and the difference was significant |
Author Commentary:
Although vasopressin has been shown to improve survival in a subset of cardiac arrests as yet there is no proven difference in overall outcome. Larger studies are required to prove a benefit of less than 25% increased survival.
Bottom Line:
Vasopressin is as efficacious as adrenaline in cardiac arrest.
Level of Evidence:
Level 3: Small numbers of small studies or great heterogeneity or very different population
References:
- Lindner KH, Dirks B, Strohmenger H, et al.. Randomised comparison of epinephrine and vasopressin in patients with out-of-hospital ventricular fibrillation.
- Stiell IG, Hebert PC, Wells GA, et al.. Vasopressin versus epinephrine for inhospital cardiac arrest: a randomised controlled trial.
- Wenzel V, Krismer A, Arntz R, et al.. A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation.