In 2008 and 2013, two prospective RCTs from Greece reported benefits from the combination of vasopressin, steroids, and epinephrine (VSE) for in-hospital cardiac arrest.  However, other studies investigating the addition of vasopressin alone to epinephrine have been negative. Consequently, vasopressin has been removed from the AHA/ACC algorithms, with a specific recommendation against the use of vasopressin in combination with epinephrine.  Meanwhile, these same guidelines contain a Class IIb recommendation to consider VSE for in-patient cardiac arrest.  How should we approach this? (1)

VSE:  Evidence about vasopressin, steroid, and epinephrine

Mentzelopoulos 2009

This was a single-center prospective double-blind trial which randomized 100 patients with in-hospital arrest to epinephrine vs. epinephrine plus a combination of three interventions: vasopressin 20 IU for up to five cycles of CPR, methylprednisolone 40 mg IV during CPR, and tapered stress-dose hydrocortisone (300 mg/d) for patients with post-arrest shock.  Patients treated with VSE had improved return of spontaneous circulation (ROSC; 81% vs. 52%; p=0.003) and survival to hospital discharge (19% vs. 4%; p=0.02).  Results were perhaps most dramatic among patients who developed post-resuscitation shock, in whom survival to discharge was 30% with VSE (8/27 patients) versus none in the control group (0/15; p=0.02).  Patients receiving VSE had decreased levels of pro-inflammatory cytokines, improved hemodynamics, and less organ failure: CONTINUE ON PULMCRIT