pituitrin and Heart-Arrest

To perform a systematic review and individual participant data meta-analysis of vasopressin and glucocorticoids for the treatment of cardiac arrest.. The PRISMA-IPD guidelines were followed. We searched Medline, Embase, and the Cochrane Library for randomized trials comparing vasopressin and glucocorticoids to placebo during cardiac arrest. The population included adults with cardiac arrest in any setting. Pairs of investigators reviewed studies for relevance, extracted data, and assessed risk of bias. Meta-analyses were conducted using individual participant data. A Bayesian framework was used to estimate posterior treatment effects assuming various prior beliefs. The certainty of evidence was evaluated using GRADE.. Three trials were identified including adult in-hospital cardiac arrests only. Individual participant data were obtained from all trials yielding a total of 869 patients. There was some heterogeneity in post-cardiac arrest interventions between the trials. The results favored vasopressin and glucocorticoids for return of spontaneous circulation (odds ratio: 2.09, 95%CI: 1.54 to 2.84, moderate certainty). Estimates for survival at discharge (odds ratio: 1.39, 95%CI: 0.90 to 2.14, low certainty) and favorable neurological outcome (odds ratio: 1.64, 95%CI, 0.99 to 2.72, low certainty) were more uncertain. The Bayesian estimates for return of spontaneous circulation were consistent with the primary analyses, whereas the estimates for survival at discharge and favorable neurological outcome were more dependent on the prior belief.. Among adults with in-hospital cardiac arrest, vasopressin and glucocorticoids compared to placebo, improved return of spontaneous circulation. Larger trials are needed to determine whether there is an effect on longer-term outcomes.

Topics: Adult; Bayes Theorem; Glucocorticoids; Heart Arrest; Hospitals; Humans; Randomized Controlled Trials as Topic; Vasopressins

Randomized controlled trials evaluating the efficacy of vasopressin versus standard of care during cardiopulmonary resuscitation (CPR) have yielded conflicting results. An electronic search of MEDLINE, Cochrane, and Embase databases was conducted through February 2022 for randomized controlled trials that evaluated the outcomes of vasopressin versus standard of care during CPR among patients with cardiac arrest. The primary outcome was the likelihood of spontaneous circulation (ROSC) return. Data were pooled using the random-effects model. The final analysis included 11 trials with 6,609 patients. The weighted mean age was 65.5 years, and 68.2% were men. There was no significant difference between the vasopressin and control groups in the likelihood of ROSC (33.1% vs 31.9%, odds ratio [OR] 1.23, 95% confidence interval [CI] 0.98 to 1.55). Subgroup analyses suggested that the use of vasopressin versus control increased the likelihood of ROSC when used in combination with steroids (p

Topics: Aged; Cardiopulmonary Resuscitation; Female; Heart Arrest; Humans; Male; Vasopressins

The role of corticosteroid therapy in patients with cardiac arrest (CA) is uncertain. We aimed to evaluate the efficacy and safety of corticosteroid therapy in CA patients.. Randomised controlled trials were identified using PubMed, EMBASE, Cochrane Central Register of Controlled Trials, the Chinese National Knowledge Infrastructure and the Chinese Biomedical Literature Database. The primary outcome was overall survival. Secondary outcomes were positive neurological status and probability of sustained restoration of spontaneous circulation (ROSC). Complications were infection and bleeding. Given the significant heterogeneity across previous studies, combining the data using meta-analysis was deemed not appropriate.. Five studies (551 patients) met the criteria. Two studies of co-intervention therapy (corticosteroid, vasopressin and epinephrine protocol) found that this approach could benefit in-hospital CA patient survival rates at hospital discharge, improve neurological function at hospital discharge and yield sustained ROSC rate. However, further two studies failed to demonstrate that corticosteroid therapy alone could improve survival and neurological outcomes among CA patients. Additionally, corticosteroid therapy did not increase the risk of infection and bleeding.. Due to the inherent limitations of the studies in this review, we have not been able to reach definitive conclusions. Larger-scale and better-designed studies are therefore recommended, to further evaluate the potential and rational use of corticosteroid therapy in CA patients.

Topics: Cardiopulmonary Resuscitation; Drug Therapy, Combination; Epinephrine; Glucocorticoids; Heart Arrest; Hemorrhage; Hospital Mortality; Humans; Infections; Randomized Controlled Trials as Topic; Risk Assessment; Survival Rate; Treatment Outcome; Vasopressins

Adrenaline and vasopressin are widely used to treat people with cardiac arrest, but there is uncertainty about the safety, effectiveness and the optimal dose.. To determine whether adrenaline or vasopressin, or both, administered during cardiac arrest, afford any survival benefit.. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase and DARE from their inception to 8 May 2018, and the International Liaison Committee on Resuscitation 2015 Advanced Life Support Consensus on Science and Treatment Recommendations. We also searched four trial registers on 5 September 2018 and checked the reference lists of the included studies and review papers to identify potential papers for review.. Any randomised controlled trial comparing: standard-dose adrenaline versus placebo; standard-dose adrenaline versus high-dose adrenaline; and adrenaline versus vasopressin, in any setting, due to any cause of cardiac arrest, in adults and children. There were no language restrictions.. Two review authors independently identified trials for review, assessed risks of bias and extracted data, resolving disagreements through re-examination of the trial reports and by discussion. We used risk ratios (RRs) with 95% confidence intervals (CIs) to compare dichotomous outcomes for clinical events. There were no continuous outcomes reported. We examined groups of trials for heterogeneity. We report the quality of evidence for each outcome, using the GRADE approach.. We included 26 studies (21,704 participants).Moderate-quality evidence found that adrenaline increased survival to hospital discharge compared to placebo (RR 1.44, 95% CI 1.11 to 1.86; 2 studies, 8538 participants; an increase from 23 to 32 per 1000, 95% CI 25 to 42). We are uncertain about survival to hospital discharge for high-dose compared to standard-dose adrenaline (RR 1.10, 95% CI 0.75 to 1.62; participants = 6274; studies = 10); an increase from 33 to 36 per 1000, 95% CI 24 to 53); standard-dose adrenaline versus vasopressin (RR 1.25, 95% CI 0.84 to 1.85; 6 studies; 2511 participants; an increase from 72 to 90 per 1000, 95% CI 60 to 133); and standard-dose adrenaline versus vasopressin plus adrenaline (RR 0.76, 95% CI 0.47 to 1.22; 3 studies; 3242 participants; a possible decrease from 24 to 18 per 1000, 95% CI 11 to 29), due to very low-quality evidence.Moderate-quality evidence found that adrenaline compared with placebo increased survival to hospital admission (RR 2.51, 95% CI 1.67 to 3.76; 2 studies, 8489 participants; an increase from 83 to 209 per 1000, 95% CI 139 to 313). We are uncertain about survival to hospital admission when comparing standard-dose with high-dose adrenaline, due to very low-quality evidence. Vasopressin may improve survival to hospital admission when compared with standard-dose adrenaline (RR 1.27, 95% CI 1.04 to 1.54; 3 studies, 1953 participants; low-quality evidence; an increase from 260 to 330 per 1000, 95% CI 270 to 400), and may make little or no difference when compared to standard-dose adrenaline plus vasopressin (RR 0.95, 95% CI 0.83 to 1.08; 3 studies; 3249 participants; low-quality evidence; a decrease from 218 to 207 per 1000 (95% CI 181 to 236).There was no evidence that adrenaline (any dose) or vasopressin improved neurological outcomes.The rate of return of spontaneous circulation (ROSC) was higher for standard-dose adrenaline versus placebo (RR 2.86, 95% CI 2.21 to 3.71; participants = 8663; studies = 3); moderate-quality evidence; an increase from 115 to 329 per 1000, 95% CI 254 to 427). We are uncertain about the effect on ROSC for the comparison of standard-dose versus high-dose adrenaline and standard-does adrenaline compared to vasopressin, due to very low-quality evidence. Standard-dose adrenaline may make little or no difference to ROSC when compared to standard-dose adrenaline plus vasopressin (RR 0.97, 95% CI 0.87 to 1.08; 3 studies, 3249 participants; low-quality evidence; a possible decrease. This review provides moderate-quality evidence that standard-dose adrenaline compared to placebo improves return of spontaneous circulation, survival to hospital admission and survival to hospital discharge, but low-quality evidence that it did not affect survival with a favourable neurological outcome. Very low -quality evidence found that high-dose adrenaline compared to standard-dose adrenaline improved return of spontaneous circulation and survival to admission. Vasopressin compared to standard dose adrenaline improved survival to admission but not return of spontaneous circulation, whilst the combination of adrenaline and vasopressin compared with adrenaline alone had no effect on these outcomes. Neither standard dose adrenaline, high-dose adrenaline,vasopressin nor a combination of adrenaline and vasopressin improved survival with a favourable neurological outcome. Many of these studies were conducted more than 20 years ago. Treatment has changed in recent years, so the findings from older studies may not reflect current practice.

Topics: Adult; Aged; Blood Circulation; Child; Child, Preschool; Epinephrine; Heart; Heart Arrest; Humans; Middle Aged; Out-of-Hospital Cardiac Arrest; Patient Admission; Patient Discharge; Placebos; Randomized Controlled Trials as Topic; Survival Analysis; Vasoconstrictor Agents; Vasopressins

evaluate the effectiveness of epinephrine used during cardiac arrest and its effect on the survival rates and neurological condition.. systematic review of scientific literature with meta-analysis, using a random effects model. The following databases were used to research clinical trials and observational studies: Medline, Embase and Cochrane, from 2005 to 2015.. when the Return of Spontaneous Circulation (ROSC) with administration of epinephrine was compared with ROSC without administration, increased rates were found with administration (OR 2.02. 95% CI 1.49 to 2.75; I2 = 95%). Meta-analysis showed an increase in survival to discharge or 30 days after administration of epinephrine (OR 1.23; 95% IC 1.05-1.44; I2=83%). Stratification by shockable and non-shockable rhythms showed an increase in survival for non-shockable rhythm (OR 1.52; 95% IC 1.29-1.78; I2=42%). When compared with delayed administration, the administration of epinephrine within 10 minutes showed an increased survival rate (OR 2.03; 95% IC 1.77-2.32; I2=0%).. administration of epinephrine appears to increase the rate of ROSC, but when compared with other therapies, no positive effect was found on survival rates of patients with favorable neurological status.. avaliar a efetividade da adrenalina na parada cardíaca e seu efeito na sobrevivência e no estado neurológico.. revisão sistemática da literatura científica com meta-análise utilizando um modelo de efeitos aleatórios. Revisão em Medline, Embase e Cochrane, desde 2005 até 2015 de ensaios clínicos e estudos observacionais.. observou-se aumento nas taxas de retorno de circulação espontânea com a administração de adrenalina (OR 2,02; 95% IC 1,49-2,75; I2=95%) comparadas com a não administração de adrenalina. A meta-análise mostrou um aumento da sobrevivência na alta ou depois de 30 dias da administração de adrenalina (OR 1,23; 95% IC 1,05-1,44; I2=83%). Quando estratificados por ritmos desfibrilháveis e não desfibrilháveis apareceu um aumento da sobrevivência nos ritmos não desfibrilháveis (OR 1,52; 95% IC 1,29-1,78; I2=42%). Também observou-se um incremento de sobrevivência na alta ou depois de 30 dias, quando administrada a adrenalina antes de 10 minutos, isto comparado com administração tardia (OR 2,03; 95% IC 1,77-2,32; I2=0%).. a administração de adrenalina parece incrementar a taxa de retorno da circulação espontânea, mas não se tem encontrado um efeito positivo nas taxas de sobrevivência nem nas taxas de pacientes com estado neurológico favorável, em comparação com outras terapias.. evaluar la efectividad de la adrenalina en el paro cardíaco y su efecto en la supervivencia y en el estado neurológico.. revisión sistemática de la literatura científica con metaanálisis utilizando un modelo de efectos aleatorios. Revisión en Medline, Embase y Cochrane, desde 2005 hasta 2015, de ensayos clínicos y estudios observacionales.. se observó aumento en las tasas de retorno de circulación espontánea cuando administrada adrenalina (OR 2,02; 95% IC 1,49-2,75; I2=95%) comparada con la no administración de adrenalina. El metaanálisis mostró un aumento de la supervivencia al alta hospitalaria o a los 30 días cuando administrada adrenalina (OR 1,23; 95% IC 1,05-1,44; I2=83%). La estratificación por ritmos desfibrilables y no desfibrilables mostró un aumento de la supervivencia en ritmos no desfibrilables (OR 1,52; 95% IC 1,29-1,78; I2=42%). También, se observó un incremento en la supervivencia al alta hospitalaria o a los 30 días en la administración de adrenalina antes de 10 minutos comparada con la administración tardía (OR 2,03; 95% IC 1,77-2,32; I2=0%).. la administración de adrenalina parece incrementar la tasa de retorno de circulación espontánea, pero no se ha encontrado un efecto positivo en tasas de supervivencia ni en tasas de pacientes con estado neurológico favorable, en comparación con otras terapias.

Topics: Epinephrine; Heart Arrest; Humans; Treatment Outcome; Vasopressins

Is a vasopressin, steroid, and epinephrine (VSE) protocol for in-hospital cardiac arrest resuscitation associated with better survival to hospital discharge with favourable neurologic outcome compared to epinephrine alone? Article chosen Mentzelopoulos S, Malachias S, Konstantopoulos D, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. JAMA 2013;310:270-9.. To determine if a VSE protocol during cardiopulmonary resuscitation with hydrocortisone administration in patients with postresuscitative shock at 4 hours after return of spontaneous circulation would improve survival to hospital discharge with favourable neurologic outcome.

Topics: Brain Ischemia; Cardiopulmonary Resuscitation; Drug Therapy, Combination; Epinephrine; Glucocorticoids; Heart Arrest; Humans; Randomized Controlled Trials as Topic; Treatment Outcome; Vasopressins

Experimental and animal studies suggested that vasopressin may have a favorable survival profile during CPR. This meta-analysis aimed to determine the efficacy of vasopressin in adult cardiac patients.. Meta-analysis of randomized control trials (RCTs) comparing the efficacy of vasopressin containing regimen during CPR in adult cardiac arrest population with an epinephrine only regimen.. A total of 6120 patients from 10 RCTs were included in this meta-analysis. Vasopressin use during CPR has no beneficial impact in an unselected population in ROSC [OR 1.19, 95% CI 0.93, 1.52], survival to hospital discharge [OR 1.13, 95% CI 0.89, 1.43], survival to hospital admission [OR 1.12, 95% CI 0.99, 1.27] and favorable neurological outcome [OR 1.02, 95% CI 0.75, 1.38]. ROSC in "in-hospital" cardiac arrest setting [OR 2.20, 95% CI 1.08, 4.47] is higher patients receiving vasopressin. Subgroup analyses revealed equal or higher chance of ROSC [OR 2.15, 95% CI 1.00, 4.61], higher possibility of survival to hospital discharge [OR 2.39, 95% CI 1.34, 4.27] and favorable neurological outcome [OR 2.58, 95% CI 1.39, 4.79] when vasopressin was used as repeated boluses of 4-5 times titrating desired effects during CPR.. ROSC in "in-hospital" cardiac arrest patients is significantly better when vasopressin was used. A subgroup analysis of this meta-analysis found that ROSC, survival to hospital admission and discharge and favorable neurological outcome may be better when vasopressin was used as repeated boluses of 4-5 times titrated to desired effects; however, overall no beneficial effect was noted in unselected cardiac arrest population.

Topics: Adult; Cardiopulmonary Resuscitation; Epinephrine; Heart Arrest; Humans; Risk Assessment; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Topics: Adult; Aged; Cardiopulmonary Resuscitation; Confidence Intervals; Dose-Response Relationship, Drug; Emergency Medicine; Emergency Service, Hospital; Epinephrine; Female; Heart Arrest; Humans; Male; Middle Aged; Odds Ratio; Randomized Controlled Trials as Topic; Risk Assessment; Survival Rate; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

In October of 2010, the American Heart Association (AHA) published the 2010 Guidelines on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. These guidelines place significant emphasis on 5 major areas of therapy in patient with cardiac arrest, including immediate recognition and activation of the emergency response team, effective chest compressions, rapid defibrillation, effective advanced life support (ALS), and integrated postresuscitation care. "Effective ALS" includes the placement of an advanced airway, establishment of parenteral access, and the administration of cardioactive medications. Advanced life support encompasses only 1 of these 5 major areas of cardiac arrest intervention-in sharp contrast to past renditions of the AHA guidelines in which ALS was significantly emphasized. In fact, recent research and the AHA guidelines note that ALS therapy is less important than previously thought. This article will briefly review the evidence regarding the use of the 5 principal medications--epinephrine, vasopressin, atropine, lidocaine, and amiodarone--used in Advanced Cardiac Life Support cardiac arrest algorithm.

Topics: Advanced Cardiac Life Support; Amiodarone; Atropine; Cardiotonic Agents; Epinephrine; Heart Arrest; Humans; Lidocaine; Practice Guidelines as Topic; Resuscitation; Vasopressins

Prior meta-analyses-reported results of randomised controlled trials (RCTs) published between 1997 and 2004 failed to show any vasopressin-related benefit in cardiac arrest. Based on new RCT-data and a hypothesis of a potentially increased vasoconstricting efficacy of vasopressin, we sought to determine whether the cumulative, current evidence supports or refutes an overall and/or selective benefit for vasopressin regarding sustained restoration of spontaneous circulation (ROSC), long-term survival, and neurological outcome.. Two reviewers independently searched PubMed, EMBASE, and Cochrane Database for RCTs assigning adults with cardiac arrest to treatment with a vasopressin-containing regimen (vasopressin-group) vs adrenaline (epinephrine) alone (control-group) and reporting on long-term outcomes. Data from 4475 patients in 6 high-methodological quality RCTs were analyzed. Subgroup analyses were conducted according to initial cardiac rhythm and time from collapse to drug administration (T(DRUG))<20 min.. Vasopressin vs. control did not improve overall rates of sustained ROSC, long-term survival, or favourable neurological outcome. However, in asystole, vasopressin vs. control was associated with higher long-term survival {odds ratio (OR)=1.80, 95% confidence interval (CI)=1.04-3.12, P=0.04}. In asystolic patients of RCTs with average T(DRUG)<20 min, vasopressin vs. control increased the rates of sustained ROSC (data available from 2 RCTs; OR=1.70, 95% CI=1.17-2.47, P=0.005) and long-term survival (data available from 3 RCTs; OR=2.84, 95% CI=1.19-6.79, P=0.02).. Vasopressin use in the resuscitation of cardiac arrest patients is not associated with any overall benefit or harm. However, vasopressin may improve the long-term survival of asystolic patients, especially when average T(DRUG) is <20 min.

Topics: Cardiopulmonary Resuscitation; Global Health; Heart Arrest; Humans; Randomized Controlled Trials as Topic; Survival Rate; Vasoconstrictor Agents; Vasopressins

Advanced Life Support guidelines recommend the use of epinephrine during Cardiopulmonary Resuscitation (CPR), as to increase coronary blood flow and perfusion pressure through its alpha-adrenergic peripheral vasoconstriction, allowing minimal rises in coronary perfusion pressure to make defibrillation possible. Contrasting to these alpha-adrenergic effects, epinephrine's beta-stimulation may have deleterious effects through an increase in myocardial oxygen consumption and a reduction of subendocardial perfusion, leading to postresuscitation cardiac dysfunction.. The present paper consists of a systematic review of the literature regarding the use of beta-blockade in cardiac arrest due to ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT).. Studies were identified through MEDLINE electronic databases research and were included those regarding the use of beta-blockade during CPR.. Beta-blockade has been extensively studied in animal models of CPR. These studies not only suggest that beta-blockade could reduce myocardial oxygen requirements and the number of shocks necessary for defibrillation, but also improve postresuscitation myocardial function, diminish arrhythmia recurrences and prolong survival. A few case reports described successful beta-blockade use in patients, along with two prospective human studies, suggesting that it could be safe and effectively used during cardiac arrest in humans.. Even though the existing literature points toward a beneficial effect of beta-blockade in patients presenting with cardiac arrest due to VF/pulseless VT, high quality human trials are still lacking to answer this question definitely.

Topics: Adrenergic beta-Antagonists; Animals; Cardiopulmonary Resuscitation; Coronary Circulation; Epinephrine; Heart Arrest; Humans; Myocardium; Oxygen Consumption; Propanolamines; Propranolol; Tachycardia, Ventricular; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

To review the literature addressing whether the use of vasopressors improves outcomes in patients who suffer cardiac arrest.. Databases were searched using the terms: "(adrenaline or noradrenaline or vasopressor) and (heart arrest or cardiac arrest) and therapy". Inclusion criteria were human studies, controlled trials, meta-analysis or case series. Exclusion criteria were articles with no abstract, abstract-only citations without accompanying article, non-English abstracts, vasopressor studies without human clinical trials, case reports, reviews, and articles addressing traumatic arrest.. 1603 papers were identified of which 53 articles were included for review. The literature addressed 5 main therapeutic questions. (1) Outcomes comparing any vasopressor to placebo. (2) Outcomes comparing vasopressin (alone or in combination with epinephrine) to epinephrine. (3) Outcomes comparing high dose epinephrine to standard dose epinephrine. (4) Outcomes comparing any alternative vasopressor to epinephrine. (5) Outcomes examining vasopressor use in pediatric cardiac arrest.. There are few studies that compare vasopressors to placebo in resuscitation from cardiac arrest. Epinephrine is associated with improvement in short term survival outcomes as compared to placebo, but no long-term survival benefit has been demonstrated. Vasopressin is equivalent for use as an initial vasopressor when compared to epinephrine during resuscitation from cardiac arrest. There is a short-term, but no long-term, survival benefit when using high dose vs. standard dose epinephrine during resuscitation from cardiac arrest. There are no alternative vasopressors that provide a long-term survival benefit when compared to epinephrine. There is limited data on the use of vasopressors in the pediatric population.

Topics: Cardiopulmonary Resuscitation; Drug Therapy, Combination; Epinephrine; Heart Arrest; Humans; Life Support Care; Norepinephrine; Vasoconstrictor Agents; Vasopressins

Topics: Animals; Clinical Trials as Topic; Epinephrine; Heart Arrest; Humans; Outcome Assessment, Health Care; Vasoconstrictor Agents; Vasopressins

Topics: Advanced Cardiac Life Support; Animals; Cardiopulmonary Resuscitation; Dose-Response Relationship, Drug; Epinephrine; Heart Arrest; Humans; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Reports of successful use of vasopressin in various shock states and cardiac arrest has lead to the emergence of vasopressin therapy as a potentially major advancement in the management of critically ill children.. To provide an overview of physiology of vasopressin, rationale of its use and dose schedule in different disease states with special focus on recent advances in the therapeutic applications of vasopressin.. MEDLINE search (1966-September 2011) using terms vasopressin, terlipressin, arginine-vasopressin, shock, septic shock, vasodilatory shock, cardiac arrest, and resuscitation for reports on vasopressin/terlipressin use in children and manual review of article bibliographies. Search was restricted to human studies. Randomized controlled trials, cohort studies, evaluation studies, case series, and case reports on vasopressin/terlipressin use in children (preterm neonates to 21 years of age) were included. Outcome measures were analysed using following clinical questions: indication, dose and duration of vasopressin/terlipressin use, main effects especially on systemic blood pressure, catecholamine requirement, urine output, serum lactate, adverse effects, and mortality.. 51 reports on vasopressin (30 reports) and terlipressin (21 reports) use in pediatric population were identified. A total of 602 patients received vasopressin/terlipressin as vasopressors in various catecholamine-resistant states (septic - 176, post-cardiotomy - 136, other vasodilatory/mixed shock - 199, and cardiac arrest - 101). Commonly reported responses include rapid improvement in systemic blood pressure, decline in concurrent catecholamine requirement, and increase in urine output; despite these effects, the mortality rates remained high.. In view of the limited clinical experience, and paucity of randomized controlled trials evaluating these drugs in pediatric population, currently no definitive recommendations on vasopressin/terlipressin use can be laid down. Nevertheless, available clinical data supports the use of vasopressin in critically ill children as a rescue therapy in refractory shock and cardiac arrest.

Topics: Adolescent; Child; Child, Preschool; Heart Arrest; Humans; Infant; Infant, Newborn; Shock; Vasoconstrictor Agents; Vasopressins; Young Adult

The best chance of survival with a good neurological outcome after cardiac arrest is afforded by early recognition and high-quality cardiopulmonary resuscitation (CPR), early defibrillation of ventricular fibrillation (VF), and subsequent care in a specialist center. Compression-only CPR should be used by responders who are unable or unwilling to perform mouth-to-mouth ventilations. After the first defibrillator shock, further rhythm checks and defibrillation attempts should be performed after 2 min of CPR. The underlying cause of cardiac arrest can be identified and treated during CPR. Drugs have a limited effect on long-term outcomes after cardiac arrest, although epinephrine improves the success of resuscitation, and amiodarone increases the success of defibrillation for refractory VF. Supraglottic airway devices are an alternative to tracheal intubation, which should be attempted only by skilled rescuers. Care after cardiac arrest includes controlled reoxygenation, therapeutic hypothermia for comatose survivors, percutaneous coronary intervention, circulatory support, and control of blood-glucose levels and seizures. Prognostication in comatose survivors of cardiac arrest needs a careful, multimodal approach using clinical and electrophysiological assessments after at least 72 h.

Topics: Airway Management; Anti-Arrhythmia Agents; Cardiopulmonary Resuscitation; Defibrillators; Epinephrine; Heart Arrest; Humans; Prognosis; Sympathomimetics; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

The vasoconstrictive and antidiuretic physiologic properties of vasopressin (antidiuretic hormone) have long been known. Until recently however, vasopressin was mostly used for diabetes insipidus and noctournal enuresis. This review summarizes the growing body of evidence regarding the perioperative use of vasopressin and its analogues in the management of certain forms of cardiovascular collapse. Physiologically, vasopressin is involved in regulating osmotic, volemic, and cardiovascular homeostasis. It acts via several specific vasopressin receptors that are variably distributed in the heart, kidneys and vasculature etc. Under normal conditions, its antidiuretic effect predominates and vasopressin only induces vasoconstriction at high concentrations. Regarding catecholamine-resistant vasodilatory shock, current evidence suggests that with adequate volume resuscitation, exogenous vasopressin in low "physiologic" doses (0.01-0.04 units/min) safely supports mean arterial pressure without adversely affecting myocardial function and splanchnic circulation. One possible explanation is that metabolic acidosis impairs the function of alpha-adrenergic (but not vasopressin) receptors, thus diminishing the response to catecholamines. Although there is yet no clear cut mortality benefit, vasopressin is now recommended as a second-line agent in septic shock for its catecholamine-sparing effect and as an alternative to epinephrine in cardiopulmonary resuscitation. It has also demonstrated efficacy in ameliorating vasoplegia after cardiopulmonary bypass as well as perioperative hypotension in patients on renin-angiotensin system antagionists preoperatively. In summary, accumulating clinical experience and formal studies indicate that vasopressin has a role in restoring vascular tone in refractory vasodilatory shock states with minimal adverse effects provided that euvolemia is assured.

Topics: Anesthesia; Animals; Antidiuretic Agents; Critical Care; Heart Arrest; Hemodynamics; Humans; Perioperative Care; Shock; Shock, Septic; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Epinephrine remains the primary vasopressor for neonatal resuscitation complicated by asystole or prolonged bradycardia not responsive to adequate ventilation and chest compressions. Epinephrine increases coronary perfusion pressure primarily through peripheral vasoconstriction. Current guidelines recommend intravenous epinephrine administration (0.01-0.03 mg/kg). Endotracheal epinephrine administration results in unpredictable absorption. High-dose intravenous epinephrine poses additional risks and does not result in better long-term survival. Vasopressin has been considered an alternative to epinephrine in adults, but there is insufficient evidence to recommend its use in newborn infants. Future research will focus on the best sequence for epinephrine administration and chest compressions.

Topics: Asphyxia Neonatorum; Epinephrine; Female; Fetal Distress; Heart Arrest; Heart Massage; Hemodynamics; Humans; Infant, Newborn; Practice Guidelines as Topic; Pregnancy; Resuscitation; Vasoconstrictor Agents; Vasopressins

Drug therapy is recommended after effective cardiopulmonary resuscitation and defibrillation in cardiac arrest. Some drugs appear to have short-term benefits, such as improved survival to hospital, e.g. vasopressor and antiarrhythmics. Hence, they have been included in the cardiac life support algorithm. However, to date, no drug (or combination of drugs) has been shown to improve long-term survival in randomised trials. Hopefully, improvements in post-arrest intensive unit care can translate improved survival in hospitals into better long-term outcomes. This review is an update on drugs during resuscitation, including the choice of agents, dosing, sequence and route. Specific drugs may have benefits in correcting identified causes of collapse. Drug usage during resuscitation is an evolving science, with the use of medications improving as results of clinical studies become available.

Topics: Advanced Cardiac Life Support; Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Heart Arrest; Humans; Injections, Intravenous; Resuscitation; Vasoconstrictor Agents; Vasopressins

Local anesthetic toxicity can have catastrophic outcome in an otherwise benign procedure. Introduction of even a small amount of local anesthetic into the bloodstream can cause cardiac arrest in a healthy patient. Most healthcare facilities rely on standard resuscitative techniques to treat such events; however, treatment via infusion of lipid emulsion has been used successfully to stabilize the condition of some patients in a safe, effective, and rapid manner. The online databases consulted included Academic Search Premier, CINAHL, and MEDLINE. The key words included in the search were "Intralipid," "local anesthetic toxicity," "lipid infusion," and "lipid sink." Lipid therapy has shown great promise for the treatment of patients facing cardiovascular collapse due to local anesthetic toxicity. However, the slow adoption of this novel evidence-based practice by healthcare facilities endangers patients who may not receive the best available care when the need is most dire. Current evidence suggests that infusion of lipid emulsion should be considered among the primary treatments for local anesthetic toxicity and be made readily available in every facility's operating or procedure room, and hospital staff should be trained in its use when local anesthetic toxicity is suspected.

Topics: Anesthetics, Local; Epinephrine; Fat Emulsions, Intravenous; Heart Arrest; Humans; Practice Guidelines as Topic; Vasopressins

To discuss 3 potential mechanisms for loss of peripheral vasomotor tone during vasodilatory shock; review vasopressin physiology; review the available animal experimental and human clinical studies of vasopressin in vasodilatory shock and cardiopulmonary arrest; and make recommendations based on review of the data for the use of vasopressin in vasodilatory shock and cardiopulmonary arrest.. Human clinical studies, veterinary experimental studies, forum proceedings, book chapters, and American Heart Association guidelines. HUMAN AND VETERINARY DATA SYNTHESIS: Septic shock is the most common form of vasodilatory shock. The exogenous administration of vasopressin in animal models of fluid-resuscitated septic and hemorrhagic shock significantly increases mean arterial pressure and improves survival. The effect of vasopressin on return to spontaneous circulation, initial cardiac rhythm, and survival compared with epinephrine is mixed. Improved survival in human patients with ventricular fibrillation, pulseless ventricular tachycardia, and nonspecific cardiopulmonary arrest has been observed in 4 small studies of vasopressin versus epinephrine. Three large studies, though, did not find a significant difference between vasopressin and epinephrine in patients with cardiopulmonary arrest regardless of initial cardiac rhythm. No veterinary clinical trials have been performed using vasopressin in cardiopulmonary arrest.. Vasopressin (0.01-0.04 U/min, IV) should be considered in small animal veterinary patients with vasodilatory shock that is unresponsive to fluid resuscitation and catecholamine (dobutamine, dopamine, and norepinephrine) administration. Vasopressin (0.2-0.8 U/kg, IV once) administration during cardiopulmonary resuscitation in small animal veterinary patients with pulseless electrical activity or ventricular asystole may be beneficial for myocardial and cerebral blood flow.

Topics: Animals; Animals, Domestic; Heart Arrest; Humans; Shock; Vasoconstrictor Agents; Vasopressins

Topics: Cardiac Surgical Procedures; Child; Heart Arrest; Humans; Sepsis; Vasoconstrictor Agents; Vasopressins

Cardiopulmonary resuscitation (CPR) after the induction of cardiac arrest (CA) has been studied in mice and rats. The anatomical and physiological parameters of the cardiopulmonary system of these two species have been defined during experimental studies and are comparable with those of humans. Moreover, these animal models are more ethical to establish and are easier to manipulate, when compared with larger experimental animals. Accordingly, the effects of successful CPR on the function of vital organs, such as the brain, have been investigated because damage to these vital organs is of concern in CA survivors. Furthermore, the efficacy of several drugs, such as adrenaline (epinephrine), vasopressin and nitroglycerin, has been evaluated for use in CA in these small animal models. The purpose of these studies is not only to increase the rate of survival of CA victims, but also to improve their quality of life by reducing damage to their vital organs after CA and during CPR.

Topics: Animals; Cardiopulmonary Resuscitation; Epinephrine; Heart Arrest; Humans; Mice; Models, Animal; Nitroglycerin; Rats; Vasopressins

No evidence supports vasopressin over epinephrine in cardiac arrest; however animal and some clinical studies support their concurrent use. This systematic review compares the efficacy of vasopressin and epinephrine used together versus repeated doses of epinephrine alone in cardiac arrest.. We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. We included randomized controlled trials (RCTs) where vasopressin and epinephrine were administered concurrently to cardiac arrest patients within the half-life of vasopressin. Two reviewers assessed studies for eligibility, data extraction and quality. Appropriateness of studies for meta-analysis was assessed. The primary outcome was survival to hospital discharge and the secondary outcome was return of spontaneous circulation (ROSC).. From 235 titles identified, we reviewed 29 abstracts. Three cardiac arrest studies were included (N=1226). Study 1 randomized vasopressin versus epinephrine then subsequent epinephrine. Study 2 randomized two doses of vasopressin versus epinephrine. Study 3 randomized vasopressin versus placebo, administered following initial epinephrine. All studies favored combination treatment for ROSC, but only study 2 was statistically significant (RR 1.42, 95% CI 1.14-1.77). Studies 1 and 2 reported survival to discharge, only study 2 was significant (RR 3.69, 95% CI 1.52-8.95). The methods for the three studies were too dissimilar to allow pooling of results.. This systematic review of the combination of vasopressin and epinephrine found trends towards better ROSC but equivocal effects on survival. At the present time, there is inadequate evidence to advocate the sequential use of vasopressin and epinephrine for cardiac arrest.

Topics: Drug Therapy, Combination; Epinephrine; Heart Arrest; Humans; Randomized Controlled Trials as Topic; Vasopressins

Vasopressin is a 9-amino acid peptide synthesized by magnocellular neurons of the hypothalamus and released from posterior pituitary gland. The primary physiological role of vasopressin is the maintenance of fluid homeostasis. In this review, the classification of vasopressin receptors, namely V1 vascular, V2 renal, V3 pituitary, oxytocin receptors, and purinergic receptors, and the effects of vasopressin on vascular smooth muscles, the heart, and the kidneys are discussed. Mortality rates of vasodilatory (or distributive), for example septic shock, are high. The use of vasopressin is an alternative therapy for vasodilatory shock with better outcome. Vasopressin is effective in resuscitation of adults after ventricular fibrillation or pulseless tachycardia, when epinephrine is not effective.

Topics: Adult; Clinical Trials as Topic; Dilatation, Pathologic; Heart; Heart Arrest; Homeostasis; Humans; Intensive Care Units; Kidney; Muscle, Smooth, Vascular; Receptors, Vasopressin; Resuscitation; Shock; Shock, Septic; Survival Analysis; Tachycardia; Time Factors; Treatment Outcome; Vasoconstrictor Agents; Vasodilation; Vasopressins; Ventricular Fibrillation

To review the physiology and the published literature on the role of vasopressin in shock in children.. We searched MEDLINE (1966-2007), EMBASE (1980-2007), and the Cochrane Library, using the terms vasopressin, terlipressin, and shock and synonyms or related terms for relevant studies in pediatrics. We searched the online ISRCTN-Current Controlled Trials registry for ongoing trials. We reviewed the reference lists of all identified studies and reviews as well as personal files to identify other published studies.. Beneficial effects have been reported in vasodilatory shock and asystolic cardiac arrest in adults. Solid evidence for vasopressin use in children is scant. Observational studies have reported an improvement in blood pressure and rapid weaning off catecholamines during administration of low-dose vasopressin. Dosing in children is extrapolated from adult studies.. Vasopressin offers promise in shock and cardiac arrest in children. However, in view of the limited experience with vasopressin, it should be used with caution. Results of a double-blind, randomized controlled trial in children with vasodilatory shock will be available soon.

Topics: Animals; Cardiopulmonary Resuscitation; Child; Clinical Trials as Topic; Critical Illness; Heart Arrest; Humans; Shock; Vasoconstrictor Agents; Vasopressins

To date, there is no evidence showing a benefit from any advanced cardiac life support (ACLS) medication in out-of-hospital cardiac arrest (OOHCA), despite animal data to the contrary. One explanation may be a difference in the time to first drug administration. Our previous work has shown the mean time to first drug administration in clinical trials is 19.4min. We hypothesized that the average time to drug administration in large animal experiments occurs earlier than in OOHCA clinical trials.. We conducted a literature review between 1990 and 2006 in MEDLINE using the following MeSH headings: swine, dogs, resuscitation, heart arrest, EMS, EMT, ambulance, ventricular fibrillation, drug therapy, epinephrine, vasopressin, amiodarone, lidocaine, magnesium, and sodium bicarbonate. We reviewed the abstracts of 331 studies and 197 full manuscripts. Exclusion criteria included: non-peer reviewed, all without primary animal data, and traumatic models. From these, we identified 119 papers that contained unique information on time to medication administration. The data are reported as mean, ranges, and 95% confidence intervals. Mean time to first drug administration in animal laboratory studies and clinical trials was compared with a t-test. Regression analysis was performed to determine if time to drug predicted ROSC.. Mean time to first drug administration in 2378 animals was 9.5min (range 3.0-28.0; 95% CI around mean 2.78, 16.22). This is less than the time reported in clinical trials (19.4min, p<0.001). Time to drug predicted ROSC (odds ratio 0.844; 95% CI 0.738, 0.966).. Shorter drug delivery time in animal models of cardiac arrest may be one reason for the failure of animal studies to translate successfully into the clinical arena.

Topics: Amiodarone; Animals; Anti-Arrhythmia Agents; Clinical Trials as Topic; Disease Models, Animal; Drug Administration Schedule; Epinephrine; Heart Arrest; Humans; Lidocaine; Life Support Care; Magnesium Sulfate; Regression Analysis; Sodium Bicarbonate; Time Factors; Vasoconstrictor Agents; Vasopressins

Vasopressin is a peptide synthesized in the hypothalamus whose primary role is in fluid homeostasis. It has recently gained interest as a potential agent in the treatment of cardiorespiratory arrest. Initial human studies have shown benefits with vasopressin in patients with out of hospital ventricular fibrillation and asystolic cardiac arrest. One subgroup of patients not included in these trials is patients with pulmonary hypertension, who have a five-year mortality rate of 50%. Animal studies have shown vasopressin to be a vasodilator in the pulmonary vascular system of rats, under normoxic and hypoxic conditions, with conflicting results in canines. Human studies have shown conflicting results with increases, decreases and no changes seen in pulmonary artery pressures of patients with a variety of clinical conditions. Research needs to be done in patients with pulmonary hypertension regarding the potential role of vasopressin during cardiac arrest in this subgroup.

Topics: Animals; Dogs; Heart Arrest; Hemostatics; Humans; Hypertension, Pulmonary; Pulmonary Circulation; Rats; Respiratory Insufficiency; Swine; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Out-of-hospital cardiac arrest (OOH-CA) is a leading cause of mortality and the focus of significant research. Recent studies provide new evidence that may change our management of OOH-CA and improve outcomes. The findings of two recently published studies of OOH-CA are reviewed in this article. The first, the Public Access Defibrillation Trial, was a randomized, controlled trial of public access defibrillation in 993 community facilities in the U.S. and Canada . It demonstrated that a community strategy to train laypersons to respond to cardiac arrests significantly increased survival to hospital discharge following OOH-CA in nonresidential community units with community members trained and equipped to provide public access defibrillation, compared to community units with community members trained to provide cardiopulmonary resuscitation (CPR) without any capacity for defibrillation. The second, the European Resuscitation Council Vasopressor during Cardiopulmonary Resuscitation Study, was a randomized, controlled, double-blinded trial that compared vasopressin to epinephrine as the initial pharmacological therapy for 1,219 patients who sustained OOH-CA. The study demonstrated that vasopressin is similar to epinephrine for OOH-CA due to ventricular fibrillation or pulseless electrical activity, and superior to epinephrine for the initial treatment of asystolic arrest; it also demonstrated that the combination of vasopressin and epinephrine is superior to epinephrine alone in the treatment of refractory, out-of-hospital cardiac arrest. Studies on alternative CPR techniques and adjunctive devices for CPR were also reviewed. We conclude that pre-hospital access to defibrillators and the use of vasopressin in the management of asystole hold promise for improving survival for patients with out-of-hospital cardiac arrest.

Topics: Antidiuretic Agents; Cardiopulmonary Resuscitation; Electric Countershock; Emergency Medical Services; First Aid; Heart Arrest; Humans; Randomized Controlled Trials as Topic; Residence Characteristics; Vasoconstrictor Agents; Vasopressins

Sudden cardiac arrest is a major public heath problem, affecting more than 450,000 individuals annually. Response time and the initiation of cardiopulmonary resuscitation (CPR) remain the most important factors determining successful revival. During resuscitation, sympathomimetics are given to enhance cerebral and coronary perfusion pressures in an attempt to achieve restoration of spontaneous circulation. Epinephrine has been the preferred vasopressor since the inception of advanced cardiac life support, although the lack of definitive evidence regarding its effectiveness has created much controversy surrounding its use, including the optimum dosage. Vasopressin is an alternative vasopressor that, when given at high doses, causes vasoconstriction by directly stimulating smooth muscle V1 receptors. The 2000 American Heart Association (AHA) guidelines commented that vasopressin is a reasonable first-line vasopressor in patients with ventricular fibrillation or pulseless ventricular tachycardia. Since release of those guidelines, additional human studies support an expanded role for vasopressin, whereas other studies cast doubt regarding its efficacy compared with epinephrine. The AHA recently released revised guidelines for CPR and emergency cardiovascular care. The consensus was that vasopressors should remain a part of pulseless sudden cardiac arrest management, with epinephrine 1 mg every 3-5 minutes being the recommended adrenergic of choice. In these revised guidelines, the role of vasopressin expanded beyond previous recommendations, despite the recommendation being downgraded to class indeterminate. The guidelines comment that one dose of vasopressin 40 U may replace the first or second dose of epinephrine in all pulseless sudden cardiac arrest scenarios, including asystole and pulseless electrical activity. A consistent theme with all vasopressors in sudden cardiac arrest is that additional studies are necessary to clearly document greater efficacy compared with no treatment. Further evaluation is warranted to better assess the role of vasopressin in asystolic sudden cardiac arrest, as well as its use with epinephrine, and to determine its optimal timing of administration and potential synergistic effects.

Topics: Arginine Vasopressin; Cardiopulmonary Resuscitation; Heart Arrest; Humans; Practice Guidelines as Topic; Treatment Outcome; Vasopressins

The use of vasopressin in patients with cardiac arrest presenting with specific rhythms is controversial. We performed an evidence-based emergency medicine review of evidence comparing vasopressin to epinephrine in structured cardiac arrest protocols.. We searched MEDLINE, EMBASE, the Cochrane Library, and other databases for randomized trials or systematic reviews comparing vasopressin to epinephrine for adults with cardiac arrest and measuring survival to hospital discharge and neurologic function in survivors. We used standard criteria to appraise the quality of published trials and systematic reviews. We used the random effects model in supplementary analyses to summarize results and to test for significant differences across subgroups of patients presenting with different arrest rhythms.. We found 3 high-quality well-reported randomized trials and 1 rigorous meta-analysis. The evidence does not confirm a consistent benefit of vasopressin over epinephrine in increasing survival or improving neurologic outcome in survivors. Subgroup analysis reveals a large difference in effect of vasopressin over epinephrine in cardiac arrest patients with asystole, compared to other arrest rhythms, coming from within-trial comparisons. The difference is not consistent across otherwise similar trials, is not statistically significant, may reflect the application of multiple unplanned subgroup analyses, and is not supported by a plausible biological hypothesis.. Evidence from randomized trials does not establish a benefit of vasopressin over epinephrine in increasing survival to discharge or improving neurologic outcomes in adult patients with nontraumatic cardiac arrest.

Topics: Brain Damage, Chronic; Emergency Medical Services; Epinephrine; Evidence-Based Medicine; Heart Arrest; Humans; Odds Ratio; Patient Discharge; Randomized Controlled Trials as Topic; Research Design; Resuscitation; Survival Analysis; Vasoconstrictor Agents; Vasopressins

This article is a review of the most recent findings in resuscitation techniques in advanced cardiac life support. The article focuses particularly on the period after July 1, 2003, but relevant new findings before this period are also included.. Randomized clinical trial results suggest that the current cardiopulmonary resuscitation and advanced cardiac life support guidelines may need to be modified. Early defibrillation during the electrical phase of cardiac arrest remains the most crucial intervention, but performing cardiopulmonary resuscitation before defibrillation may be more effective, as compared with immediate defibrillation, during the circulatory phase of cardiac arrest. Biphasic waveforms are superior to monophasic damped sine waveforms in achieving defibrillation. Novel cardiopulmonary resuscitation methods that increase negative intrathoracic pressure promote an increase in blood flow return to the heart. These devices have been correlated with improved short-term survival rates during the circulatory phase of cardiac arrest. Vasopressin administration, given alone or in combination with epinephrine, should be considered during the circulatory phase of out-of-hospital cardiac arrest, particularly in patients presenting with asystole as the initial rhythm. Induction of hypothermia during the metabolic phase in cardiac arrest survivors improves 6-month survival rates and neurologic outcomes.. Strategies to improve the low survival outcomes of cardiac arrest victims are available. Clinical trials testing these strategies suggest benefit from certain interventions but are not definitive. These different therapeutic interventions should be performed in a phase-specific-oriented fashion according to the three-phase time-sensitive model of cardiac arrest.

Topics: Amiodarone; Anti-Arrhythmia Agents; Cardiopulmonary Resuscitation; Clinical Trials as Topic; Electric Countershock; Emergency Medical Services; Epinephrine; Heart Arrest; Humans; Hypothermia, Induced; Life Support Care; Practice Guidelines as Topic; Time Factors; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

The current guidelines for cardiopulmonary resuscitation recommend vasopressin as an alternative to epinephrine for the treatment of adult shock-refractory ventricular fibrillation. The objective of this study was to determine the effectiveness of vasopressin in the treatment of cardiac arrest.. We performed a systematic review and meta-analysis of 1519 patients with cardiac arrest from 5 randomized controlled trials that compared vasopressin and epinephrine. Two reviewers conducted a systematic search of electronic databases, complemented by hand searches, to identify randomized trials. Reviewers evaluated the quality of the trials, extracted data, and derived pooled estimates using a random-effects model.. There were no statistically significant differences between the vasopressin and epinephrine groups in failure of return of spontaneous circulation (risk ratio [RR], 0.81; 95% confidence interval [CI], 0.58-1.12), death before hospital admission (RR, 0.72; 95% CI, 0.38-1.39), death within 24 hours (RR, 0.74; 95% CI, 0.38-1.43), death before hospital discharge (RR, 0.96; 95% CI, 0.87-1.05), or combination of number of deaths and neurologically impaired survivors (RR, 1.00; 95% CI, 0.94-1.07). Subgroup analysis based on initial cardiac rhythm showed no statistically significant difference in the rate of death before hospital discharge between the vasopressin and epinephrine groups in any of the 3 subgroups: ventricular fibrillation or ventricular tachycardia (RR, 0.97; 95% CI, 0.79-1.19), pulseless electrical activity (RR, 1.02; 95% CI, 0.95-1.10), or asystole (RR, 0.97; 95% CI, 0.94-1.00).. There is no clear advantage of vasopressin over epinephrine in the treatment of cardiac arrest. Guidelines for Advanced Cardiac Life Support should not recommend vasopressin in resuscitation protocols until more solid human data on its superiority are available.

Topics: Bias; Confidence Intervals; Heart Arrest; Humans; Odds Ratio; Randomized Controlled Trials as Topic; Risk Assessment; Treatment Outcome; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

According to scientific publications focusing on emergency medicine and published in international journals in the past few months, new and clinically important results can be identified. In patients with severe head trauma (SHT), application of hypertonic solutions is possible; long term outcome, however, is not improved by this measure. Prehospital capnometry is important, because otherwise up to 40 % of all mechanically ventilated patients are hypoventilated. In a study in 200 patients with prehospital cardiac arrest and ventricular fibrillation as initial cardiac rhythm, subgroup analysis (alarm-response time > 5 min) showed an increase in survival rate (14 % vs. 2 %), if defibrillation was proceeded by 3 min of conventional cardiopulmonary resuscitation (CPR) for reperfusion. If ACD ("active compression decompression")-CPR is combined with a specific ventilatory valve ("inspiratory impedance threshold device", ITD) which does not allow passive inspiration, survival rate after cardiac arrest is increased for up to 24 h. Such a device facilitates an increase in venous return to the heart during decompression of the thorax. High-dose adrenalin for intrahospital CPR in children is not associated with better survival but with worse outcome. Comparison of an emergency medical service (EMS) system from U.K. with paramedics and a physician-staffed German EMS system demonstrated that survival rate following prehospital cardiac arrest is markedly increased with doctors on board. The European multicentre trial comparing vasopressin vs. adrenalin as first vasopressor during CPR in 1219 patients did not reveal any differences between both groups. In subgroup analyses of patients with asystoly and prolonged CPR, vasopressin was superior without being associated with a benefit on neurological outcome. Further subgroup analyses revealed beneficial effects of amiodarone and thrombolysis during CPR. Thrombolysis during CPR apears to be associated with an increased rate of haemodynamic stabilisation without increased risk of bleeding complications. In a very clear advisory statement, the "International Liaison Committee on Resuscitation" (ILCOR) has recommended mild therapeutic hypothermia (i. e., cooling of cardiac arrest victims to 32 - 34 degrees C central body temperature for 12 - 24 h following cardiac arrest of cardiac etiology) not only for unconciuous patients with ventricular fibrillation as initial prehospital rhythm, but also for all other adult patients (ot

Topics: Cardiopulmonary Resuscitation; Craniocerebral Trauma; Electric Countershock; Emergency Medicine; Epinephrine; Heart Arrest; Humans; Hypertonic Solutions; Hypothermia, Induced; Multiple Trauma; Prognosis; Respiration, Artificial; Thrombolytic Therapy; Vasoconstrictor Agents; Vasopressins

Initiation of effective cardiopulmonary resuscitation (CPR) at the earliest possible moment is the most important determinant of prognosis for prehospital cardiac arrest. The prognosis is essentially defined by two parameters: survival to hospital admission and survival to discharge. In connection with prehospital cardiac arrest, early defibrillation is particularly important, including the widespread availability of (semi)automatic defibrillators. Further aspects of CPR have recently received increased attention: on the one hand, changed study status regarding the use of antiarrhythmic agents (especially amiodarone), on the other hand, administration of vasopressin during resuscitation, and finally, the efficacy of mild hypothermia following prehospital cardiac arrest. These aspects represent the main subject of the present overview, which also addresses the latest revision of the International Liaison Committee on Resuscitation (ILCOR) guidelines on CPR that resulted in corresponding changes in the European Resuscitation Council (ERC) guidelines.

Topics: Amiodarone; Anti-Arrhythmia Agents; Cardiopulmonary Resuscitation; Defibrillators; Emergency Medical Services; Europe; Heart Arrest; Hospital Mortality; Humans; Hypothermia, Induced; Practice Guidelines as Topic; Risk Factors; Survival Analysis; Vasopressins

Intervention for cardiac arrest may require intervention for electrical abnormalities or hemodynamic instability. These actions can result in ineffective cardiac functioning and systemic hypotension. Vasopressors are capable of improving severe hypotension that can result from reduced cardiovascular contractility or heart rate. These vasopressor actions are critical to successful resuscitation efforts for patients.

Topics: Cardiopulmonary Resuscitation; Dobutamine; Dopamine; Epinephrine; Heart Arrest; Heart Rate; Humans; Hypotension; Myocardial Contraction; Norepinephrine; Nurse's Role; Receptors, Adrenergic; Severity of Illness Index; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Epinephrine (adrenaline) and vasopressin have been by far the most commonly studied vasopressors in experimental cardiac arrest. Despite animal experimental studies suggesting improved outcomes in experimental cardiac arrest, clinical trials of pressor agents have failed to show clear cut benefit from either vasopressin or epinephrine, although few, if any, trials compared pressor agents to a placebo. The action of vasopressors in the heart, particularly beta1-adrenergic stimulation, is associated with adverse cardiac effects including post-resuscitation myocardial dysfunction, worsening ventricular arrhythmias, and increasing myocardial oxygen consumption. Alpha2-adrenergic agonists, in experimental studies, show great promise in improving outcomes in experimental cardiac arrest, but have not been studied in humans. The combination of epinephrine and vasopressin may be effective, but has been incompletely studied. Clinical trials of vasopressor agents, which minimize direct myocardial effects are needed.

Topics: Animals; Cardiopulmonary Resuscitation; Disease Models, Animal; Drug Evaluation; Drug Therapy, Combination; Epinephrine; Heart Arrest; Humans; Practice Guidelines as Topic; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

To review the efficacy and safety of vasopressin in cardiac arrest.. MEDLINE, EMBASE, and PubMed were searched (all to June 2005) for full-text English-language publications describing trials in humans. Search terms were vasopressin, epinephrine, adrenaline, heart arrest, cardiac arrest, and clinical trial.. Prospective, randomized, controlled trials that evaluated efficacy or safety endpoints of vasopressin in the management of cardiac arrest were included. Efficacy outcomes included return of spontaneous circulation, successful resuscitation, survival to hospital admission, 24-hour survival, and survival to hospital discharge. Safety outcomes were as defined by each trial.. Three prospective trials were identified and included in this review. Vasopressin does not appear to offer any therapeutic advantage compared with epinephrine in the treatment of both in-hospital and out-of-hospital cardiac arrest, regardless of the presenting arrest rhythm. Although there is a suggestion that vasopressin may be effective in treatment of asystole, the evidence for this arises from a subgroup analysis that should be viewed as hypothesis generating. There are limited data describing the safety of vasopressin in cardiac arrest.. The current evidence for the use of vasopressin in cardiac arrest is indeterminate. Given the similarly equivocal evidence of efficacy for epinephrine, either drug could be considered the first-line agent in cardiac arrest. Placebo-controlled studies with appropriate statistical power are warranted to evaluate meaningful clinical outcomes, such as survival to hospital discharge. Further evaluation of the role of vasopressin in asystolic cardiac arrest and its use in combination with epinephrine is also justified.

Topics: Clinical Trials as Topic; Coronary Circulation; Databases, Bibliographic; Epinephrine; Heart Arrest; Humans; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Historically, epinephrine has been used in the treatment of cardiac arrest for its alpha effects of peripheral vasoconstriction to promote vital organ perfusion. Unfortunately, epinephrine, like many other pharmacological agents, targets other receptor sites that can have a detrimental effect on the patient in cardiac arrest. Vasopressin is an endogenous hormone that may be an ideal alternative or adjunctive to epinephrine in the setting of cardiac arrest. Vasopressin, like epinephrine, promotes selective but potent vasoconstriction of smooth muscle, but unlike epinephrine, without the potentially harmful side effects of increasing myocardial workload, therefore increasing oxygen demand and subsequent worsening of cardiac function. The newest data on the impact of vasopressin in cardiac arrest is promising. Further studies are required to determine if vasopressin has a significantly positive impact in outcome as measured by discharge of the neurologically intact patient in the North American EMS model.

Topics: Cardiopulmonary Resuscitation; Drug Therapy, Combination; Emergency Medical Services; Epinephrine; Heart Arrest; Humans; Vasoconstrictor Agents; Vasopressins

Topics: Accidents, Traffic; Aged; Air Ambulances; Diagnosis, Differential; Fatal Outcome; Heart Arrest; Humans; Male; Multiple Trauma; Resuscitation; Shock, Hemorrhagic; Vasopressins

Vasopressin and its analogue, terlipressin, are potent vasopressors that may be useful therapeutic agents in the treatment of cardiac arrest, septic and catecholamine-resistant shock and oesophageal variceal haemorrhage. The aim of this article is to review the physiology and pharmacology of vasopressin and summarise its efficacy and safety in clinical trials and its subsequent therapeutic use. Recent studies indicate that the use of vasopressin during cardiopulmonary resuscitation may improve the survival of patients with asystolic cardiac arrest. Vasopressin deficiency can contribute to refractory shock states associated with sepsis, cardiogenic shock and cardiac arrest. Low doses of vasopressin and terlipressin can restore vasomotor tone in conditions that are resistant to catecholamines, with preservation of renal blood flow and urine output. They are also useful in reducing bleeding and mortality associated with oesophageal variceal haemorrhage. The long-term outcome of the use of these drugs is not known.

Topics: Animals; Esophageal and Gastric Varices; Heart Arrest; Humans; Lypressin; Shock; Terlipressin; Vasoconstrictor Agents; Vasopressins

In patients undergoing cardiopulmonary resuscitation, circulating endogenous vasopressin concentrations were significantly higher in successfully resuscitated patients than in patients who died. These observations have prompted several investigations to assess the role of vasopressin to improve cardiopulmonary resuscitation management.. Literature review.. In the cardiopulmonary resuscitation laboratory, vasopressin improved vital organ blood flow, cerebral oxygen delivery, the probability of restoring spontaneous circulation, and neurologic recovery better than epinephrine. In pediatric preparations with asphyxia, epinephrine was superior to vasopressin, whereas in both pediatric pigs with ventricular fibrillation and adult porcine models with asphyxia, combinations of vasopressin and epinephrine proved to be highly effective. In addition, vasopressin enabled short- and long-term survival in a porcine model of uncontrolled hemorrhagic shock. In a recently published European, multiple-center trial, 1,219 adult patients with out-of-hospital cardiac arrest were randomized to receive two injections of either 40 IU of vasopressin or 1 mg of epinephrine followed by additional epinephrine if needed. The clinical study did not confirm laboratory data showing vasopressin to be more effective than epinephrine in ventricular fibrillation and pulseless electrical activity, but vasopressin was superior to epinephrine in patients with asystole. Vasopressin followed by epinephrine was more effective than epinephrine alone in the treatment of refractory cardiac arrest.. According to new data from the European vasopressin study, we suggest, first, the administration of 1 mg of epinephrine, followed alternately by 40 IU of vasopressin and 1 mg of epinephrine every 3 mins in adult cardiac arrest victims, regardless of the initial electrocardiographic rhythm.

Topics: Advanced Cardiac Life Support; Animals; Epinephrine; Europe; Heart Arrest; Humans; Randomized Controlled Trials as Topic; Swine; Vasoconstrictor Agents; Vasopressins

Vasopressin is one of the most important endogenously released stress hormones during shock. In this review, studies published in the past year that add to our understanding of the use of vasopressin in the ICU are discussed.. Endogenous vasopressin levels are inappropriately low in adults with severe sepsis but not in children with meningococcal septic shock. Vasopressin but not norepinephrine improved renal blood flow and oxygen delivery and prolonged survival in animal models of septic shock. In human vasodilatory shock, the combination of low-dose vasopressin and norepinephrine was found to be safe and effective. In humans, vasopressin can cause gastrointestinal hypoperfusion and ischemic skin lesions. In hypodynamic animal models of sepsis vasopressin compromised oxygen delivery and decreased systemic and gut blood flow.High-dose bolus vasopressin appeared promising in animal studies of hemorrhagic shock and cardiopulmonary arrest and in a large, randomized clinical trial of vasopressin versus epinephrine in human cardiopulmonary arrest with asystole. However, poor neurologic outcomes raised controversy in introducing vasopressin into CPR guidelines.. There is growing evidence that vasopressin infusion in septic shock is safe and effective. Several studies published this year support the hypothesis that vasopressin should be used as a continuous low-dose infusion (between 0.01 and 0.04 U/min in adults) and not titrated as a single vasopressor agent. However, multiple studies highlight the clinical equipoise that exists regarding the use of vasopressin in vasodilatory shock. Guidelines on management of septic shock recommend "cautious use of vasopressin pending further studies."

Topics: Animals; Heart Arrest; Humans; Intensive Care Units; Shock, Hemorrhagic; Shock, Septic; Time Factors; Vasoconstrictor Agents; Vasopressins

Shock-resistant ventricular fibrillation is defined as ventricular fibrillation persisting after three defibrillation attempts. In approximately 10 to 25% of all cardiac arrests, shock-resistant ventricular fibrillation develops, and 87 to 98% of these patients die.. In the treatment of shock-resistant ventricular fibrillation, defibrillation using biphasic waveforms is considered as an intervention of choice. Intravenous amiodarone is also acceptable, safe, and useful, based on evidence from two randomized clinical trials. Intravenous vasopressin is acceptable and probably safe and useful, but the evidence supporting this recommendation is coming from a small, randomized clinical trial. Procainamide is acceptable but not recommended. In the presence of acute myocardial infarction and recurrent ventricular fibrillation, if all other therapies fail, beta-blockers can be considered. Magnesium, lidocaine, and bretylium are not recommended in the treatment of shock-resistant ventricular fibrillation.. Biphasic defibrillation and intravenous amiodarone are useful in shock-resistant ventricular fibrillation.

Topics: Adrenergic beta-Antagonists; Amiodarone; Anti-Arrhythmia Agents; Bretylium Compounds; Cardiopulmonary Resuscitation; Electric Countershock; Heart Arrest; Hemodynamics; Humans; Lidocaine; Magnesium; Procainamide; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

The primary goal of cardiopulmonary resuscitation is to reestablish blood flow to vital organs until spontaneous circulation is restored. Adrenergic vasopressor agents produce systemic vasoconstriction. This increases aortic diastolic pressure, and consequently, coronary and cerebral perfusion pressures. The pharmacologic responses to the adrenergic agents are mediated by a group of receptors that are classified as alpha (alpha), including alpha1 and alpha2, and beta (beta), including beta1 and beta2. Epinephrine, which has each of these adrenergic actions, has been the preferred adrenergic agent for the management of cardiac arrest for almost 40 years. Its primary efficacy is due to its alpha-adrenergic vasopressor effects. This contrasts with its beta-adrenergic actions, which are inotropic, chronotropic, and vasodilator. Accordingly, beta-adrenergic actions prompt increases in myocardial oxygen consumption, ectopic ventricular arrhythmias, and transient hypoxemia due to pulmonary arteriovenous shunting. This may account for the failure to demonstrate that epinephrine improves ultimate outcomes in human victims of cardiac arrest. Major interest has more recently been focused on selective alpha-adrenergic agonists. Both alpha1-agonists and alpha2-agonists are peripheral vasopressors. However, rapid desensitization of alpha1-adrenergic receptors occurs during cardiopulmonary resuscitation. Moreover, alpha1-adrenergic receptors are present in the myocardium, and beta1-agonists, like beta-adrenergic agonists, increase myocardial oxygen consumption. If they cross the blood-brain barrier, alpha2-adrenoceptor agonists also have centrally acting vasodilator effects. In the absence of central nervous system access, alpha2-adrenergic agonists have selective peripheral vasoconstrictor effects. Under experimental conditions of cardiopulmonary resuscitation, selective alpha2-agonists, which do not gain entrance into the brain, produce only systemic vasoconstriction. Experimentally, these selective alpha2-agonists are as effective as epinephrine for initial cardiac resuscitation and have the additional advantage of minimizing myocardial oxygen consumption during the global myocardial ischemia of cardiac arrest. Accordingly, myocardial ischemic injury during cardiopulmonary resuscitation is minimized, and postresuscitation myocardial function is preserved with improved survival.

Topics: Adrenergic alpha-Agonists; Adrenergic beta-Agonists; Animals; Brain Ischemia; Cardiopulmonary Resuscitation; Epinephrine; Heart Arrest; Humans; Vasoconstrictor Agents; Vasopressins

A short cut review was carried out to establish whether vasopressin is more effective than adrenaline after cardiac arrest. Altogether 44 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

Topics: Aged; Cardiopulmonary Resuscitation; Epinephrine; Heart Arrest; Humans; Male; Vasoconstrictor Agents; Vasopressins

Vasopressin is a potent endogenous vasoconstrictor that increases blood pressure and systemic vascular resistance. The administration of exogenous vasopressin during closed and open cardiopulmonary resuscitation in humans was shown to be more effective than optimal doses of epinephrine in several clinical studies. We summarize here the recent experimental and clinical data on the use of vasopressin in cardiopulmonary resuscitation and septic shock. As the use of vasopressin in human resuscitation is now in its early stages, it is expected that accumulated future experience will shed more light regarding the risk-benefit aspects of its use.

Topics: Animals; Heart Arrest; Humans; Shock; Vasoconstrictor Agents; Vasopressins

Vasopressin is currently recommended in the management of patients with cardiac arrest, but its efficacy is still incompletely established. We systematically reviewed randomized trials comparing vasopressin to control treatment in the management of cardiac arrest in humans and animals. Two human and 33 animal studies were retrieved. At pooled analysis vasopressin appeared equivalent to adrenaline (epinephrine) in the management of human cardiac arrest (N=240), with, respectively 63 (78/124) vs 59% (68/116) ROSC (P=0.43), and 16 (20/124) vs 14% (16/116) survival to hospital discharge (P=0.52). In animal trials (N=669) vasopressin appeared instead significantly superior to both placebo (ROSC, respectively 93 [98/105] vs 19% [14/72], P<0.001) or adrenaline (ROSC, respectively 84 [225/268] vs 52% [117/224], P<0.001). In conclusion, vasopressin is superior to both placebo or adrenaline in animal models of cardiopulmonary resuscitation. Evidence in humans is still limited and confidence intervals estimates too wide to reliably confirm or disprove results obtained in experimental animal settings.

Topics: Animals; Disease Models, Animal; Epinephrine; Female; Heart Arrest; Humans; Italy; Life Support Care; Male; Probability; Randomized Controlled Trials as Topic; Risk Assessment; Sensitivity and Specificity; Survival Analysis; Treatment Outcome; Vasopressins

Basic life support and rapid defibrillation for ventricular fibrillation or pulseless ventricular tachycardia are the only two interventions that have been shown unequivocally to improve survival after cardiac arrest. Several drugs are advocated to treat cardiac arrest, but despite very encouraging animal data, no drug has been reliably proven to increase survival to hospital discharge after cardiac arrest. This review focuses on recent experimental and clinical data concerning the use of vasopressin, amiodarone, magnesium, and fibrinolytics during advanced life support (ALS). Animal data indicate that, in comparison with epinephrine (adrenaline), vasopressin produces better vital organ blood flow during cardiopulmonary resuscitation (CPR). These apparent advantages have yet to be converted into improved survival in large-scale trials of cardiac arrest in humans. Data from two prospective, randomized trials suggest that amiodarone may improve short-term survival after out-of-hospital ventricular fibrillation cardiac arrest. On the basis of anecdotal data, magnesium is recommended therapy for torsades de pointes and for shock-resistant ventricular fibrillation associated with hypomagnesemia. In the past, CPR has been a contraindication to giving fibrinolytics, but several studies have demonstrated the relative safety of fibrinolysis during and after CPR. Fibrinolytics are likely to be beneficial when cardiac arrest is associated with plaque rupture and fresh coronary thrombus or massive pulmonary embolism. Fibrinolysis may also improve cerebral microcirculatory perfusion once a spontaneous circulation has been restored. A planned, prospective, randomized trial may help to define the role of fibrinolysis during out-of-hospital CPR.

Topics: Advanced Cardiac Life Support; Animals; Anti-Arrhythmia Agents; Critical Care; Dose-Response Relationship, Drug; Epinephrine; Female; Fibrinolytic Agents; Heart Arrest; Humans; Male; Sensitivity and Specificity; Survival Analysis; Time Factors; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Topics: Animals; Epinephrine; Heart Arrest; Humans; Randomized Controlled Trials as Topic; Shock; Vasoconstrictor Agents; Vasopressins

The antidiuretic hormone (ADH) vasopressin is a simple peptide hormone with a number of complex, essential physiological actions. It is becoming clear that this hormone is developing an important therapeutic role in a number of different conditions. These include vasodilatory shock due to sepsis or cardiac surgery, cardiac arrest, and prolonged/excessive bleeding caused by, for example, variceal haemorrhage. This article reviews the physiology of ADH relevant to these actions and scrutinises the evidence for its therapeutic applications.

Topics: Heart Arrest; Hemorrhage; Hemostatics; Humans; Renal Agents; Shock; Thoracic Surgery; Vasoconstrictor Agents; Vasopressins

The chain of survival concept implies that provision of early access, early advanced care, including early intravenous drugs would improve survival in sudden cardiac arrest. Intravenous adrenaline (epinephrine) has been used as the drug of choice since 1906. What is the evidence for its effectiveness? Is vasopressin a better alternative?. We performed a systematic literature search in order to answer these questions. Evidence from the clinical trials that have been conducted on this subject was reviewed.. Experimental evidence confirms the beneficial effect adrenaline has on coronary perfusion pressure. However, adrenaline has not been shown conclusively to improve survival in clinical trials. Extensive trials have also failed to show any benefit of high-dose adrenaline over standard doses. Vasopressin seems to be more effective than adrenaline in animal studies for treatment of cardiac arrest due to resistant ventricular fibrillation. However, it has yet to be proven to be superior to adrenaline in clinical trials.. More research is needed into this area, especially randomised controlled trials studying the effectiveness of vasopressin. Meanwhile, in order to improve survival from sudden cardiac arrest, continuing effort should be made to achieve early initiation of cardiopulmonary resuscitation, early defibrillation and early advanced care.

Topics: Critical Care; Death, Sudden, Cardiac; Dose-Response Relationship, Drug; Drug Administration Schedule; Epinephrine; Female; Heart Arrest; Humans; Infusions, Intravenous; Male; Probability; Randomized Controlled Trials as Topic; Survival Analysis; Treatment Outcome; Vasopressins; Ventricular Fibrillation

The importance of vital organ perfusion in patients suffering cardiac arrest makes arterial vasomotor tone, and the resultant perfusion pressure, critical in resuscitation from sudden death. Although there are multiple mechanisms that may affect arterial vascular tone, historically, the therapy most commonly used has been catecholamine-induced adrenergic receptor stimulation, with catecholamine epinephrine being the commonest drug used. Over the last decade, however, it has become widely known that the utility of epinephrine during cardiopulmonary resuscitation is undefined. This has led to research into alternative agents, in particular nonadrenergic vasoactive peptides. Other agents appear promising. This article addresses pressor drugs and adrenergic agonists, including a review of their history, basic science, mechanism of action, and efficacy. Epinephrine is reviewed.

Topics: Adrenergic beta-Agonists; Cardiopulmonary Resuscitation; Chemotherapy, Adjuvant; Clinical Trials as Topic; Combined Modality Therapy; Epinephrine; Female; Heart Arrest; Humans; Male; Risk Assessment; Sensitivity and Specificity; Survival Rate; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Epinephrine during cardiopulmonary resuscitation (CPR) is being discussed controversially due to its beta-receptor mediated adverse effects such as increased myocardial oxygen consumption, ventricular arrhythmias, ventilation-perfusion defect, postresuscitation myocardial dysfunction, ventricular arrhythmias and cardiac failure. In the CPR laboratory simulating adult pigs with ventricular fibrillation or postcountershock pulseless electrical activity, vasopressin improved vital organ blood flow, cerebral oxygen delivery, resuscitability, and neurological recovery better than did epinephrine. In paediatric preparations with asphyxia, epinephrine was superior to vasopressin, whereas in both paediatric pigs with ventricular fibrillation, and adult porcine models with asphyxia, combinations of vasopressin and epinephrine proved to be highly effective. This may suggest that a different efficiency of vasopressors in paediatric vs. adult preparations; and different effects of dysrhythmic vs. asphyxial cardiac arrest on vasopressor efficiency may be of significant importance. Whether these theories can be extrapolated to humans is unknown at this point in time. In patients with out-of-hospital ventricular fibrillation, a larger proportion of patients treated with vasopressin survived 24 h compared with patients treated with epinephrine; during in-hospital CPR, comparable short-term survival was found in groups treated with either vasopressin or epinephrine. Currently, a large trial of out-of-hospital cardiac arrest patients being treated with vasopressin vs. epinephrine is ongoing in Germany, Austria and Switzerland. The new CPR guidelines of both the American Heart Association, and European Resuscitation Council recommend 40 U vasopressin intravenously, and 1 mg epinephrine intravenously as equally effective for the treatment of adult patients in ventricular fibrillation; however, no recommendation for vasopressin was made to date for adult patients with asystole and pulseless electrical activity, and paediatrics due to lack of clinical data. When adrenergic vasopressors were unable to maintain arterial blood pressure in patients with vasodilatory shock, continuous infusions of vasopressin ( approximately 0.04 to approximately 0.1 U/min) stabilised cardiocirculatory parameters, and even ensured weaning from catecholamines.

Topics: Animals; Cardiopulmonary Resuscitation; Heart Arrest; Humans; Shock, Septic; Swine; Vasoconstrictor Agents; Vasopressins

Topics: Adrenergic alpha-Agonists; Adrenergic beta-Agonists; Advanced Cardiac Life Support; Algorithms; Anti-Arrhythmia Agents; Bicarbonates; Bradycardia; Calcium Channel Blockers; Cardiac Pacing, Artificial; Cardiotonic Agents; Dobutamine; Dopamine; Electric Countershock; Electrocardiography; Epinephrine; Heart Arrest; Humans; Injections, Intravenous; Isoproterenol; Sympathomimetics; Tachycardia; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation; Verapamil

Vital organ blood flow during cardiopulmonary resuscitation (CPR) and neurologic recovery after CPR were significantly better in pigs treated with vasopressin compared with epinephrine. Furthermore, two clinical studies evaluating both out-of-hospital and inhospital cardiac arrest patients found higher 24-hr survival rates in patients who were resuscitated with vasopressin compared with epinephrine. Scientists at the Leopold Franzens University in Innsbruck, Austria, are currently coordinating a multicenter, randomized clinical trial under the aegis of the European Resuscitation Council to study the effects of vasopressin vs. epinephrine in out-of-hospital cardiac arrest patients. Results of anticipated 1,500 enrolled patients may be available in 2001 and may help to determine the role of vasopressin during CPR. Another new, recently studied vasopressor for CPR is endothelin-1. To date, this vasopressor has only been studied as an intervention in animal CPR models, although plasma levels have been investigated in cardiac arrest patients. Initial reports found improved coronary perfusion pressure when combined with epinephrine. However, the CPR research group of the University of Arizona Sarver Heart Center found excessive vasoconstriction and worse survival than with epinephrine alone.

Topics: Advanced Cardiac Life Support; Animals; Endothelin-1; Heart Arrest; Humans; Survival Rate; Swine; Vasoconstrictor Agents; Vasopressins

The survival rate of patients undergoing cardiopulmonary resuscitation (CPR) is 5% to 15%. New treatment approaches under investigation for CPR include the use of vasopressin as a vasopressor, amiodarone for the treatment of ventricular tachyarrhythmia, and adenosine antagonists (i.e., theophylline) for bradyasystolic rhythms. More innovative approaches include the use of thyroid hormone and endothelin.

Topics: Amiodarone; Animals; Anti-Arrhythmia Agents; Antihypertensive Agents; Cardiopulmonary Resuscitation; Endothelin-1; Heart Arrest; Humans; Vasoconstrictor Agents; Vasopressins

After failure of initial external defibrillation, restoration of spontaneous circulation is largely contingent on rapid and effective reversal of myocardial ischemia by both mechanical and pharmacologic means. Despite the introduction of modern cardiopulmonary resuscitation (CPR) more than 35 years ago, its universal acceptance, and its wide implementation, no improvements in outcome excepting early defibrillation have been documented over these many years. The science of CPR therefore is still in its infancy. It was incorrectly assumed that all that needs to be known is known and that the need for scientific research was therefore not apparent. Accordingly, serious resuscitation research was neither encouraged nor equitably supported. The ABCs of CPR currently provide for the establishment of a patent airway (A) and intermittent positive pressure ventilation, preferably with oxygen-enriched air (B). These are to be immediately followed with precordial compression (C). This ordering of priorities, however, is based on consensus rather than objective outcome measurements. The ABCs recently have been seriously challenged on the basis of results of both experimental and clinical studies. Conventional external precordial compression restores systemic blood flow. It may be used by both professional and nonprofessional CPR providers, especially bystanders, because of its apparent simplicity and noninvasiveness. However, manual or mechanical external precordial compression typically generates cardiac outputs that represent less than 30% of normal values. Coronary blood flow, which is critical for restoration of spontaneous circulation, is correspondingly reduced. Accordingly, several alternatives to conventional precordial compression have been proposed with the intent of increasing cardiac output and both coronary and cerebral blood flows. Among the large number of pharmaceutical agents initially recommended for cardiac resuscitation, only agents that produce peripheral vasoconstriction are of proved benefit. Epinephrine has been the preferred vasopressor agent for the management of cardiac arrest for more than 35 years because of its alpha-adrenergic effects. However, the potentially adverse effects of epinephrine are related to its beta-adrenergic inotropic actions. The beta-adrenergic actions account for disproportionate increases in myocardial oxygen consumption with increased severity of myocardial ischemic injury and provocation of ectopic ventricular tac

Topics: Adrenergic alpha-Agonists; Adrenergic beta-Agonists; Adult; Cardiopulmonary Resuscitation; Electric Countershock; Epinephrine; Extracorporeal Circulation; Heart Arrest; History, 16th Century; History, 18th Century; History, 19th Century; History, 20th Century; History, Ancient; Humans; Myocardial Infarction; Myocardium; Oxygen Consumption; Phenylephrine; Vasoconstrictor Agents; Vasopressins

Topics: Animals; Clinical Trials as Topic; Epinephrine; Heart Arrest; Humans; Resuscitation; Survival Rate; Vasopressins

While these preliminary results in humans seem promising, no large trials have been conducted to compare vasopressin and epinephrine in CPR. At this time, standard guidelines using epinephrine are still preferred.

Topics: Cardiopulmonary Resuscitation; Epinephrine; Heart Arrest; Humans; Vasoconstrictor Agents; Vasopressins

The Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest (VAM-IHCA) trial demonstrated a significant improvement in return of spontaneous circulation (ROSC) with no clear effect on long-term outcomes. The objective of the current manuscript was to evaluate the hemodynamic effects of intra-cardiac arrest vasopressin and methylprednisolone during the first 24 hours after ROSC.. The VAM-IHCA trial randomized patients with in-hospital cardiac arrest to a combination of vasopressin and methylprednisolone or placebo during the cardiac arrest. This study is a post hoc analysis focused on the hemodynamic effects of the intervention after ROSC. Post-ROSC data on the administration of glucocorticoids, mean arterial blood pressure, heart rate, blood gases, vasopressor and inotropic therapy, and sedation were collected. Total vasopressor dose between the two groups was calculated based on noradrenaline-equivalent doses for adrenaline, phenylephrine, terlipressin, and vasopressin.. The present study included all 186 patients who achieved ROSC in the VAM IHCA-trial of which 100 patients received vasopressin and methylprednisolone and 86 received placebo. The number of patients receiving glucocorticoids during the first 24 hours was 22/86 (26%) in the placebo group and 14/100 (14%) in the methylprednisolone group with no difference in the cumulative hydrocortisone-equivalent dose. There was no significant difference between the groups in the mean cumulative noradrenaline-equivalent dose (vasopressin and methylprednisolone: 603 ug/kg [95CI% 227; 979] vs. placebo: 651 ug/kg [95CI% 296; 1007], mean difference -48 ug/kg [95CI% -140; 42.9], p = 0.30), mean arterial blood pressure, or lactate levels. There was no difference between groups in arterial blood gas values and vital signs.. Treatment with vasopressin and methylprednisolone during cardiac arrest caused no difference in mean arterial blood pressure, vasopressor use, or arterial blood gases within the first 24 hours after ROSC when compared to placebo.

Topics: Cardiopulmonary Resuscitation; Gases; Heart Arrest; Hemodynamics; Hospitals; Humans; Methylprednisolone; Norepinephrine; Vasoconstrictor Agents; Vasopressins

The primary results from the Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest (VAM-IHCA) trial have previously been reported. The objective of the current manuscript is to report long-term outcomes.. The VAM-IHCA trial was a multicenter, randomized, double-blind, placebo-controlled trial conducted at ten hospitals in Denmark. Adult patients (age ≥ 18 years) were eligible for the trial if they had an in-hospital cardiac arrest and received at least one dose of epinephrine during resuscitation. The trial drugs consisted of 40 mg methylprednisolone (Solu-Medrol®, Pfizer) and 20 IU of vasopressin (Empressin®, Amomed Pharma GmbH) given as soon as possible after the first dose of epinephrine. This manuscript report outcomes at 6 months and 1 year including survival, survival with favorable neurological outcome, and health-related quality of life.. 501 patients were included in the analysis. At 1 year, 15 patients (6.3%) in the intervention group and 22 patients (8.3%) in the placebo group were alive corresponding to a risk ratio of 0.76 (95% CI, 0.41-1.41). A favorable neurologic outcome at 1 year, based on the Cerebral Performance Category score, was observed in 14 patients (5.9%) in the intervention group and 20 patients (7.6%) in the placebo group (risk ratio, 0.78 [95% CI, 0.41-1.49]. No differences existed between groups for favorable neurological outcome and health-related quality of life at either 6 months or 1 year.. Administration of vasopressin and methylprednisolone, compared with placebo, in patients with in-hospital cardiac arrest did not improve long-term outcomes in this trial.

Topics: Adolescent; Adult; Cardiopulmonary Resuscitation; Epinephrine; Heart Arrest; Hospitals; Humans; Methylprednisolone; Quality of Life; Vasopressins

Previous trials have suggested that vasopressin and methylprednisolone administered during in-hospital cardiac arrest might improve outcomes.. To determine whether the combination of vasopressin and methylprednisolone administered during in-hospital cardiac arrest improves return of spontaneous circulation.. Multicenter, randomized, double-blind, placebo-controlled trial conducted at 10 hospitals in Denmark. A total of 512 adult patients with in-hospital cardiac arrest were included between October 15, 2018, and January 21, 2021. The last 90-day follow-up was on April 21, 2021.. Patients were randomized to receive a combination of vasopressin and methylprednisolone (n = 245) or placebo (n = 267). The first dose of vasopressin (20 IU) and methylprednisolone (40 mg), or corresponding placebo, was administered after the first dose of epinephrine. Additional doses of vasopressin or corresponding placebo were administered after each additional dose of epinephrine for a maximum of 4 doses.. The primary outcome was return of spontaneous circulation. Secondary outcomes included survival and favorable neurologic outcome at 30 days (Cerebral Performance Category score of 1 or 2).. Among 512 patients who were randomized, 501 met all inclusion and no exclusion criteria and were included in the analysis (mean [SD] age, 71 [13] years; 322 men [64%]). One hundred of 237 patients (42%) in the vasopressin and methylprednisolone group and 86 of 264 patients (33%) in the placebo group achieved return of spontaneous circulation (risk ratio, 1.30 [95% CI, 1.03-1.63]; risk difference, 9.6% [95% CI, 1.1%-18.0%]; P = .03). At 30 days, 23 patients (9.7%) in the intervention group and 31 patients (12%) in the placebo group were alive (risk ratio, 0.83 [95% CI, 0.50-1.37]; risk difference: -2.0% [95% CI, -7.5% to 3.5%]; P = .48). A favorable neurologic outcome was observed in 18 patients (7.6%) in the intervention group and 20 patients (7.6%) in the placebo group at 30 days (risk ratio, 1.00 [95% CI, 0.55-1.83]; risk difference, 0.0% [95% CI, -4.7% to 4.9%]; P > .99). In patients with return of spontaneous circulation, hyperglycemia occurred in 77 (77%) in the intervention group and 63 (73%) in the placebo group. Hypernatremia occurred in 28 (28%) and 27 (31%), in the intervention and placebo groups, respectively.. Among patients with in-hospital cardiac arrest, administration of vasopressin and methylprednisolone, compared with placebo, significantly increased the likelihood of return of spontaneous circulation. However, there is uncertainty whether this treatment results in benefit or harm for long-term survival.. ClinicalTrials.gov Identifier: NCT03640949.

Topics: Aged; Cardiovascular Agents; Confidence Intervals; Denmark; Double-Blind Method; Epinephrine; Female; Glucocorticoids; Heart Arrest; Humans; Hyperglycemia; Hyponatremia; Male; Methylprednisolone; Neurologic Examination; Placebos; Return of Spontaneous Circulation; Treatment Outcome; Uncertainty; Vasoconstrictor Agents; Vasopressins

To compare the efficacy of epinephrine plus vasopressin vs epinephrine plus placebo in the pediatric intensive care unit (PICU) cardiopulmonary resuscitation (CPR).. Randomized, double-blind controlled clinical trial.. PICU in a tertiary care institute from February, 2019 to May, 2020.. Children aged one month to 13 years who required CPR during PICU stay. Patients in whom vascular access was not available or return of spontaneous circulation (ROSC) was achieved by defibrillation without epinephrine were excluded.. Patients were randomized to receive vasopressin 0.1 mL per kg (=0.8 unit per kg) or placebo (0.1 mL per kg normal saline) in addition to epinephrine (1:10000) 0.1 mL per kg. The drugs were given as bolus doses every three minutes until the ROSC or up to a maximum of five doses, whichever was earlier.. The primary outcome was the proportion of patients who achieved ROSC. The secondary outcomes were survival rate and functional status (at 24-hour, PICU, hospital, and 90-day post-discharge), need for organ supports, length of stay (PICU and hospital), and adverse effect(s) of the study drugs.. 90 patients (epinephrine plus vasopressin group, n=45 and epinephrine plus placebo group, n=45) were analyzed on intention-to-treat basis. There was no significant difference in the primary outcome between epinephrine plus vasopressin (n=25, 55.5%) and epinephrine plus placebo groups (n=24, 53.3%) (Relative risk 1.04, 95% CI 0.71 to 1.52). There was no significant difference in survival rate at 24-hour (n=7, 15.6% vs. n=8, 17.8%), at PICU, hospital, and 90-day post-discharge (n=1, 2.2% vs n=1, 2.2%). There was no difference in other secondary outcomes. No trial drug-related serious adverse events were observed.. A combination of epinephrine plus vasopressin did not improve the rate of return of spontaneous circulation in the pediatric intensive care unit cardiopulmonary resuscitation as compared with epinephrine plus placebo.

Topics: Aftercare; Cardiopulmonary Resuscitation; Child; Epinephrine; Heart Arrest; Humans; Intensive Care Units, Pediatric; Patient Discharge; Vasopressins

Purposes of this study were to compare tibial intraosseous (TIO) and intravenous (IV) administration of vasopressin relative to return of spontaneous circulation (ROSC) and time to ROSC in an adult swine cardiac arrest model. In addition, the purposes were to compare the concentration maximum (Cmax), time to maximum concentration (Tmax), and odds of ROSC.. This was a between-subjects, prospective experimental study. Yorkshire swine (N = 21) were randomly assigned to 1 of 3 groups: TIO, IV, or control groups. The swine were anesthetized and instrumented, and then cardiac arrest was induced and sustained for 2 minutes. Cardiopulmonary resuscitation was initiated and continued for 2 minutes. Vasopressin was then administered via the TIO or IV route. Blood samples were collected for 4 minutes to determine the Cmax and Tmax of vasopressin. Concentration maximum and Tmax were calculated by use of liquid chromatography with mass spectrometry.. There was no difference in ROSC between the TIO and IV groups (P = .63). The Cmax of vasopressin was significantly higher in the IV group compared to the TIO group (P = .017). However, there was no significant difference in ROSC, time to ROSC, or Tmax between groups (P > .05). All subjects had ROSC in both the IV and TIO groups, and none had ROSC in the control group. There was 225 times greater chance of survival for both the IV and TIO groups compared to the control group.. The data support that the TIO is an effective route for vasopressin in a cardiac arrest model.

Topics: Animals; Cardiopulmonary Resuscitation; Chromatography, Liquid; Disease Models, Animal; Heart Arrest; Infusions, Intraosseous; Infusions, Intravenous; Mass Spectrometry; Prospective Studies; Swine; Tibia; Vasopressins

Among patients with cardiac arrest, preliminary data have shown improved return of spontaneous circulation and survival to hospital discharge with the vasopressin-steroids-epinephrine (VSE) combination.. To determine whether combined vasopressin-epinephrine during cardiopulmonary resuscitation (CPR) and corticosteroid supplementation during and after CPR improve survival to hospital discharge with a Cerebral Performance Category (CPC) score of 1 or 2 in vasopressor-requiring, in-hospital cardiac arrest.. Randomized, double-blind, placebo-controlled, parallel-group trial performed from September 1, 2008, to October 1, 2010, in 3 Greek tertiary care centers (2400 beds) with 268 consecutive patients with cardiac arrest requiring epinephrine according to resuscitation guidelines (from 364 patients assessed for eligibility).. Patients received either vasopressin (20 IU/CPR cycle) plus epinephrine (1 mg/CPR cycle; cycle duration approximately 3 minutes) (VSE group, n = 130) or saline placebo plus epinephrine (1 mg/CPR cycle; cycle duration approximately 3 minutes) (control group, n = 138) for the first 5 CPR cycles after randomization, followed by additional epinephrine if needed. During the first CPR cycle after randomization, patients in the VSE group received methylprednisolone (40 mg) and patients in the control group received saline placebo. Shock after resuscitation was treated with stress-dose hydrocortisone (300 mg daily for 7 days maximum and gradual taper) (VSE group, n = 76) or saline placebo (control group, n = 73).. Return of spontaneous circulation (ROSC) for 20 minutes or longer and survival to hospital discharge with a CPC score of 1 or 2.. Follow-up was completed in all resuscitated patients. Patients in the VSE group vs patients in the control group had higher probability for ROSC of 20 minutes or longer (109/130 [83.9%] vs 91/138 [65.9%]; odds ratio [OR], 2.98; 95% CI, 1.39-6.40; P = .005) and survival to hospital discharge with CPC score of 1 or 2 (18/130 [13.9%] vs 7/138 [5.1%]; OR, 3.28; 95% CI, 1.17-9.20; P = .02). Patients in the VSE group with postresuscitation shock vs corresponding patients in the control group had higher probability for survival to hospital discharge with CPC scores of 1 or 2 (16/76 [21.1%] vs 6/73 [8.2%]; OR, 3.74; 95% CI, 1.20-11.62; P = .02), improved hemodynamics and central venous oxygen saturation, and less organ dysfunction. Adverse event rates were similar in the 2 groups.. Among patients with cardiac arrest requiring vasopressors, combined vasopressin-epinephrine and methylprednisolone during CPR and stress-dose hydrocortisone in postresuscitation shock, compared with epinephrine/saline placebo, resulted in improved survival to hospital discharge with favorable neurological status.. clinicaltrials.gov Identifier: NCT00729794.

Topics: Adrenergic beta-Agonists; Aged; Aged, 80 and over; Brain; Cardiopulmonary Resuscitation; Double-Blind Method; Drug Therapy, Combination; Epinephrine; Female; Glasgow Outcome Scale; Heart Arrest; Hemostatics; Humans; Hydrocortisone; Inpatients; Male; Methylprednisolone; Middle Aged; Neuroprotective Agents; Patient Discharge; Shock; Survival Analysis; Treatment Outcome; Vasopressins

To compare vasopressin and adrenaline in the treatment of patients with cardiac arrest presenting to or in the Emergency Department (ED).. A randomised, double-blind, multi-centre, parallel-design clinical trial in four adult hospitals.. Eligible cardiac arrest patients (confirmed by the absence of pulse, unresponsiveness and apnea) aged >16 (aged>21 for one hospital) were randomly assigned to intravenous adrenaline (1mg) or vasopressin (40 IU) at ED. Patients with traumatic cardiac arrest or contraindication for cardiopulmonary resuscitation (CPR) were excluded. Patients received additional open label doses of adrenaline as per current guidelines. Primary outcome was survival to hospital discharge (defined as participant discharged alive or survival to 30 days post-arrest).. The study recruited 727 participants (adrenaline = 353; vasopressin = 374). Baseline characteristics of the two groups were comparable. Eight participants (2.3%) from adrenaline and 11 (2.9%) from vasopressin group survived to hospital discharge with no significant difference between groups (p = 0.27, RR = 1.72, 95% CI = 0.65-4.51). After adjustment for race, medical history, bystander CPR and prior adrenaline given, more participants survived to hospital admission with vasopressin (22.2%) than with adrenaline (16.7%) (p = 0.05, RR = 1.43, 95% CI = 1.02-2.04). Sub-group analysis suggested improved outcomes for vasopressin in participants with prolonged arrest times.. Combination of vasopressin and adrenaline did not improve long term survival but seemed to improve survival to admission in patients with prolonged cardiac arrest. Further studies on the effect of vasopressin combined with therapeutic hypothermia on patients with prolonged cardiac arrest are needed.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cardiopulmonary Resuscitation; Double-Blind Method; Emergency Service, Hospital; Epinephrine; Female; Heart Arrest; Humans; Male; Middle Aged; Out-of-Hospital Cardiac Arrest; Survival Analysis; Treatment Outcome; Vasoconstrictor Agents; Vasopressins; Young Adult

Infusion of a vasopressor during cardiopulmonary resuscitation (CPR) in humans increases end decompression (diastolic) arterial blood pressure, and consequently increases vital organ perfusion pressure and survival. Several vasoactive drugs have been tested alone or in combination, but their hemodynamic effects have not been investigated clinically in humans.. We tested the hypothesis that epinephrine (1 mg) co-administered with vasopressin (40 IU) ± nitroglycerin (300 μg) results in higher diastolic blood pressure than epinephrine alone.. A prospective, randomized, double-blinded controlled trial in the prehospital setting. The study included 48 patients with witnessed cardiac arrest. Patients received either epinephrine alone (E alone) or epinephrine plus vasopressin (E+V) or epinephrine plus vasopressin plus nitroglycerin (E+V+N). A femoral arterial catheter was inserted for arterial pressure measurement.. The primary end point was diastolic blood pressure during CPR, 15 min after the first drug administration (T = 15 min).. After exclusions, a total of 44 patients were enrolled. Diastolic blood pressures (mm Hg) at T = 15 min were not statistically different between groups (median [interquartile range]: 20 [10], 15 [6], and 15 [13] for E alone, E+V, and E+V+N, respectively. The rate of return of spontaneous circulation was 63% (n = 10) in the epinephrine group, 43% (n = 6) in the epinephrine plus vasopressin group, and 36% (n = 5) in the triple therapy group (NS).. Addition of vasopressin or vasopressin plus nitroglycerin to epinephrine did not increase perfusion blood pressure compared to epinephrine alone in humans in cardiac arrest, suggesting the absence of benefit in using these drug combination(s).

Topics: Aged; Blood Pressure; Cardiopulmonary Resuscitation; Diastole; Double-Blind Method; Drug Therapy, Combination; Epinephrine; Female; Heart Arrest; Humans; Male; Middle Aged; Nitroglycerin; Paris; Prospective Studies; Vasoconstrictor Agents; Vasodilator Agents; Vasopressins

Animal data on cardiac arrest showed improved long-term survival with combined vasopressin-epinephrine. In cardiac arrest, cortisol levels are relatively low during and after cardiopulmonary resuscitation. We hypothesized that combined vasopressin-epinephrine and corticosteroid supplementation during and after resuscitation may improve survival in refractory in-hospital cardiac arrest.. We conducted a single-center, prospective, randomized, double-blind, placebo-controlled, parallel-group trial. We enrolled 100 consecutive patients with cardiac arrest requiring epinephrine according to current resuscitation guidelines. Patients received either vasopressin (20 IU per cardiopulmonary resuscitation cycle) plus epinephrine (1 mg per resuscitation cycle) (study group; n = 48) or isotonic sodium chloride solution placebo plus epinephrine (1 mg per resuscitation cycle) (control group; n = 52) for the first 5 resuscitation cycles after randomization, followed by additional epinephrine if needed. On the first resuscitation cycle, study group patients received methylprednisolone sodium succinate (40 mg) and controls received saline placebo. Postresuscitation shock was treated with stress-dose hydrocortisone sodium succinate (300 mg daily for 7 days maximum, with gradual taper) (27 patients in the study group) or saline placebo (15 patients in the control group). Primary end points were return of spontaneous circulation for 15 minutes or longer and survival to hospital discharge.. Study group patients vs controls had more frequent return of spontaneous circulation (39 of 48 patients [81%] vs 27 of 52 [52%]; P = .003) and improved survival to hospital discharge (9 [19%] vs 2 [4%]; P = .02). Study group patients with postresuscitation shock vs corresponding controls had improved survival to hospital discharge (8 of 27 patients [30%] vs 0 of 15 [0%]; P = .02), improved hemodynamics and central venous oxygen saturation, and more organ failure-free days. Adverse events were similar in the 2 groups.. In this single-center trial, combined vasopressin-epinephrine and methylprednisolone during resuscitation and stress-dose hydrocortisone in postresuscitation shock improved survival in refractory in-hospital cardiac arrest.. clinicaltrials.gov Identifier: NCT00411879.

Topics: Adult; Aged; Aged, 80 and over; Cardiopulmonary Resuscitation; Cause of Death; Confidence Intervals; Cross-Over Studies; Dose-Response Relationship, Drug; Double-Blind Method; Drug Therapy, Combination; Emergency Service, Hospital; Epinephrine; Female; Follow-Up Studies; Heart Arrest; Hospital Mortality; Hospitalization; Humans; Infusions, Intravenous; Intensive Care Units; Kaplan-Meier Estimate; Male; Methylprednisolone; Middle Aged; Probability; Proportional Hazards Models; Prospective Studies; Reference Values; Risk Assessment; Survival Rate; Treatment Outcome; Vasopressins

The efficacy of repeated administration of vasopressin alone during prolonged cardiopulmonary resuscitation (CPR) remains unconfirmed. This study was conducted to estimate the effectiveness of the repeated administration of vasopressin vs. epinephrine for cardiopulmonary arrest (CPA) patients receiving prolonged CPR.. We conducted a prospective randomized controlled study on patients who experienced out-of-hospital CPA. The patients were randomly assigned to receive a maximum of four injections of either 40IU of vasopressin (vasopressin group) or 1mg of epinephrine (epinephrine group) immediately after emergency room (ER) admission. Patients who received vasopressors before ER admission or suffered non-cardiogenic CPA were excluded after randomization.. In total, 336 patients were enrolled (vasopressin group, n=137; epinephrine group, n=118). No differences were found between these groups (vasopressin group vs. epinephrine group) in the rates of return of spontaneous circulation (ROSC) (28.7% vs. 26.6%), 24-h survival (16.9% vs. 20.3%), or survival to hospital discharge (5.6% vs. 3.8%). In a subgroup analysis by the Fisher's exact test, the rate of ROSC was higher in the vasopressin group than in the epinephrine group, among the patients whose arrests were witnessed (48.1% vs. 27.8%, p=0.010) or who received bystander CPR (68.0% vs. 38.5%, p=0.033). When the independent predictors of ROSC were calculated in the subgroup analysis, however, vasopressin administration (Odds ratio: 0.87-0.28) did not affect the outcome.. This is the first report of a possible vasopressin-alone resuscitation without additional epinephrine. However, repeated injections of either vasopressin or epinephrine during prolonged advanced cardiac life support resulted in comparable survival.

Topics: Aged; Aged, 80 and over; Cardiopulmonary Resuscitation; Dose-Response Relationship, Drug; Drug Administration Schedule; Female; Heart Arrest; Humans; Male; Middle Aged; Survival Rate; Time Factors; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

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.. 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.. 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).. 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.)

Topics: Adult; Aged; Cardiopulmonary Resuscitation; Drug Therapy, Combination; Emergency Medical Services; Epinephrine; Female; Follow-Up Studies; France; Heart Arrest; Humans; Male; Middle Aged; Risk; Survival Analysis; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Vasopressin administration has been suggested during cardiopulmonary resuscitation, and a previous clinical trial has suggested that vasopressin is most effective when administered with epinephrine. Adult subjects (n = 325) who received > or =1 dose of intravenous epinephrine during cardiopulmonary resuscitation for nontraumatic, out-of-hospital cardiac arrest were randomly assigned to receive 40 IU of vasopressin (n = 167) or placebo (n = 158) as soon as possible after the first dose of epinephrine. The rate of return of pulses was similar between the vasopressin and placebo groups (31% vs 30%), as was the presence of pulses at the emergency department (19% vs 23%). No subgroup appeared to be differentially affected, and no effect of vasopressin was evident after adjustment for other clinical variables. Additional open-label vasopressin was administered by a physician after the study drug for 19 subjects in the placebo group and 27 subjects in the vasopressin group. Results were similar if these subjects were excluded or were assigned to an actual drug received. Survival duration for subjects admitted to the hospital did not differ between groups. In conclusion, vasopressin administered with epinephrine does not increase the rate of return of spontaneous circulation.

Topics: Aged; Cardiopulmonary Resuscitation; Chi-Square Distribution; Drug Therapy, Combination; Emergency Medical Services; Epinephrine; Female; Heart Arrest; Humans; Logistic Models; Male; Survival Rate; Sympathomimetics; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Topics: Cardiopulmonary Resuscitation; Double-Blind Method; Drug Therapy, Combination; Epinephrine; Heart Arrest; Humans; Vasopressins; Ventricular Fibrillation

Vasopressin is an alternative to epinephrine for vasopressor therapy during cardiopulmonary resuscitation, but clinical experience with this treatment has been limited.. We randomly assigned adults who had had an out-of-hospital cardiac arrest to receive two injections of either 40 IU of vasopressin or 1 mg of epinephrine, followed by additional treatment with epinephrine if needed. The primary end point was survival to hospital admission, and the secondary end point was survival to hospital discharge.. A total of 1219 patients underwent randomization; 33 were excluded because of missing study-drug codes. Among the remaining 1186 patients, 589 were assigned to receive vasopressin and 597 to receive epinephrine. The two treatment groups had similar clinical profiles. There were no significant differences in the rates of hospital admission between the vasopressin group and the epinephrine group either among patients with ventricular fibrillation (46.2 percent vs. 43.0 percent, P=0.48) or among those with pulseless electrical activity (33.7 percent vs. 30.5 percent, P=0.65). Among patients with asystole, however, vasopressin use was associated with significantly higher rates of hospital admission (29.0 percent, vs. 20.3 percent in the epinephrine group; P=0.02) and hospital discharge (4.7 percent vs. 1.5 percent, P=0.04). Among 732 patients in whom spontaneous circulation was not restored with the two injections of the study drug, additional treatment with epinephrine resulted in significant improvement in the rates of survival to hospital admission and hospital discharge in the vasopressin group, but not in the epinephrine group (hospital admission rate, 25.7 percent vs. 16.4 percent; P=0.002; hospital discharge rate, 6.2 percent vs. 1.7 percent; P=0.002). Cerebral performance was similar in the two groups.. The effects of vasopressin were similar to those of epinephrine in the management of ventricular fibrillation and pulseless electrical activity, but vasopressin was superior to epinephrine in patients with asystole. Vasopressin followed by epinephrine may be more effective than epinephrine alone in the treatment of refractory cardiac arrest.

Topics: Aged; Cardiopulmonary Resuscitation; Drug Therapy, Combination; Emergency Medical Services; Epinephrine; Female; Heart Arrest; Hospitalization; Humans; Male; Middle Aged; Multivariate Analysis; Survival Rate; Sympathomimetics; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

Survival rates for cardiac arrest patients, both in and out of hospital, are poor. Results of a previous study suggest better outcomes for patients treated with vasopressin than for those given epinephrine, in the out-of-hospital setting. Our aim was to compare the effectiveness and safety of these drugs for the treatment of in-patient cardiac arrest.. We did a triple-blind randomised trial in the emergency departments, critical care units, and wards of three Canadian teaching hospitals. We assigned adults who had cardiac arrest and required drug therapy to receive one dose of vasopressin 40 U or epinephrine 1 mg intravenously, as the initial vasopressor. Patients who failed to respond to the study intervention were given epinephrine as a rescue medication. The primary outcomes were survival to hospital discharge, survival to 1 h, and neurological function. Preplanned subgroup assessments included patients with myocardial ischaemia or infarction, initial cardiac rhythm, and age.. We assigned 104 patients to vasopressin and 96 to epinephrine. For patients receiving vasopressin or epinephrine survival did not differ for hospital discharge (12 [12%] vs 13 [14%], respectively; p50.67; 95% CI for absolute increase in survival 211.8% to 7.8%) or for 1 h survival (40 [39%] vs 34 [35%]; p50.66; 210.9% to 17.0%); survivors had closely similar median mini-mental state examination scores (36 [range 19-38] vs 35 [20-40]; p50.75) and median cerebral performance category scores (1 vs 1).. We failed to detect any survival advantage for vasopressin over epinephrine. We cannot recommend the routine use of vasopressin for inhospital cardiac arrest patients, and disagree with American Heart Association guidelines, which recommend vasopressin as alternative therapy for cardiac arrest.

Topics: Aged; Arrhythmias, Cardiac; Cognition Disorders; Double-Blind Method; Epinephrine; Female; Heart Arrest; Hospitalization; Humans; Hypertension; Infarction; Male; Mental Status Schedule; Mesentery; Middle Aged; Ontario; Resuscitation; Safety; Survival Analysis; Time Factors; Treatment Outcome; Vasopressins

Studies in animals have suggested that intravenous vasopressin is associated with better vital-organ perfusion and resuscitation rates than is epinephrine in the treatment of cardiac arrest. We did a randomised comparison of vasopressin with epinephrine in patients with ventricular fibrillation in out-of-hospital cardiac arrest.. 40 patients in ventricular fibrillation resistant to electrical defibrillation were prospectively and randomly assigned epinephrine (1 mg intravenously; n = 20) or vasopressin (40 U intravenously; n = 20) as primary drug therapy for cardiac arrest. The endpoints of this double blind study were successful resuscitation (hospital admission), survival for 24 h, survival to hospital discharge and neurological outcome (Glasgow coma scale). Analyses were by intention to treat.. Seven (35%) patients in the epinephrine group and 14 (70%) in the vasopressin group survived to hospital admission (p = 0.06). At 24 h, four (20%) epinephrine-treated patients and 12 (60%) vasopressin-treated patients were alive (p = 0.02). Three (15%) patients in the epinephrine group and eight (40%) in the vasopressin group survived to hospital discharge (p = 0.16). Neurological outcomes were similar (mean Glasgow coma score at hospital discharge 10.7 [SE 3.8] vs 11.7 [1.6], p = 0.78).. In this preliminary study, a significantly larger proportion of patients created with vasopressin than of those treated with epinephrine were resuscitated successfully from out-of-hospital ventricular fibrillation and survived for 24 h. Based upon these findings, larger multicentre studies of vasopressin in the treatment of cardiac arrest are needed.

Topics: Aged; Double-Blind Method; Electric Countershock; Emergency Medical Services; Epinephrine; Female; Heart Arrest; Humans; Male; Middle Aged; Prospective Studies; Resuscitation; Vasopressins; Ventricular Fibrillation

To determine the hemodynamic effect of vasopressin on coronary perfusion pressure (CPP) in prolonged human cardiac arrest.. A prospective, open-label clinical trial of vasopressin during cardiac resuscitation was performed. Ten patients presenting in cardiac arrest initially received resuscitative measures by emergency physicians according to Advanced Cardiac Life Support (ACLS) guidelines. A central venous catheter for fluid and drug administration and a femoral artery catheter for measurement of CPP (aortic minus right atrial relaxation phase pressures) were placed. When each patient was deemed nonsalvageable, 1.0 mg epinephrine was given and CPP was measured for 5 minutes, followed by a dose of vasopressin (1.0 U/kg). CPP measurements were continued for another 5 minutes.. The mean duration of cardiac arrest (out-of-hospital interval plus duration of ED ACLS) was 39.6 +/- 16.5 min. There was no improvement in CPP after 1.0 mg of epinephrine. Vasopressin administration resulted in a significant increase of CPP in 4 of the 10 patients. Patients responding to vasopressin had a mean increase in CPP of 28.2 +/- 16.4 mm Hg (range: 10-51.5), with these peak increases occurring at 15 seconds to 4 minutes after administration. The increases in the vasopressin levels after administration did not differ between the responders and nonresponders.. In this human model of prolonged cardiac arrest, 40% of the patients receiving vasopressin had a significant increase in CPP. This pilot study suggests that investigation of earlier use of vasopressin as a therapeutic alternative in the treatment of cardiac arrest is warranted.

Topics: Adult; Aged; Aged, 80 and over; Cardiopulmonary Resuscitation; Confidence Intervals; Coronary Circulation; Dose-Response Relationship, Drug; Emergency Service, Hospital; Female; Heart Arrest; Hemodynamics; Humans; Male; Middle Aged; Pilot Projects; Pressure; Prospective Studies; Sampling Studies; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Topics: Heart Arrest; Hospitals; Humans; Methylprednisolone; Return of Spontaneous Circulation; Vasopressins

Topics: Heart Arrest; Hospitals; Humans; Methylprednisolone; Return of Spontaneous Circulation; Vasopressins

Topics: Heart Arrest; Hospitals; Humans; Methylprednisolone; Return of Spontaneous Circulation; Vasopressins

Topics: Heart Arrest; Hospitals; Humans; Methylprednisolone; Return of Spontaneous Circulation; Vasopressins

Topics: Heart Arrest; Hospitals; Humans; Steroids; Vasopressins

Clinical providers have access to a number of pharmacologic agents during in-hospital cardiac arrest. Few studies have explored medication administration patterns during in-hospital cardiac arrest. Herein, we examine trends in use of pharmacologic interventions during in-hospital cardiac arrest both over time and with respect to the American Heart Association Advanced Cardiac Life Support guideline updates.. Observational cohort study.. Hospitals contributing data to the American Heart Association Get With The Guidelines-Resuscitation database between 2001 and 2016.. Adult in-hospital cardiac arrest patients.. The percentage of patients receiving epinephrine, vasopressin, amiodarone, lidocaine, atropine, bicarbonate, calcium, magnesium, and dextrose each year were calculated in patients with shockable and nonshockable initial rhythms. Hierarchical multivariable logistic regression was used to determine the annual adjusted odds of medication administration. An interrupted time series analysis was performed to assess change in atropine use after the 2010 American Heart Association guideline update.. A total of 268,031 index in-hospital cardiac arrests were included. As compared to 2001, the adjusted odds ratio of receiving each medication in 2016 were epinephrine (adjusted odds ratio, 1.5; 95% CI, 1.3-1.8), vasopressin (adjusted odds ratio, 1.5; 95% CI, 1.1-2.1), amiodarone (adjusted odds ratio, 3.4; 95% CI, 2.9-4.0), lidocaine (adjusted odds ratio, 0.2; 95% CI, 0.2-0.2), atropine (adjusted odds ratio, 0.07; 95% CI, 0.06-0.08), bicarbonate (adjusted odds ratio, 2.0; 95% CI, 1.8-2.3), calcium (adjusted odds ratio, 2.0; 95% CI, 1.7-2.3), magnesium (adjusted odds ratio, 2.2; 95% CI, 1.9-2.7; p < 0.0001), and dextrose (adjusted odds ratio, 2.8; 95% CI, 2.3-3.4). Following the 2010 American Heart Association guideline update, there was a downward step change in the intercept and slope change in atropine use (p < 0.0001).. Prescribing patterns during in-hospital cardiac arrest have changed significantly over time. Changes to American Heart Association Advanced Cardiac Life Support guidelines have had a rapid and substantial effect on the use of a number of commonly used in-hospital cardiac arrest medications.

Topics: Aged; Amiodarone; Anti-Arrhythmia Agents; Atropine; Bicarbonates; Calcium; Epinephrine; Female; Glucose; Guideline Adherence; Heart Arrest; Hospitalization; Humans; Lidocaine; Logistic Models; Magnesium; Male; Middle Aged; Odds Ratio; Practice Guidelines as Topic; Practice Patterns, Physicians'; Vasoconstrictor Agents; Vasopressins

Topics: Epinephrine; Heart Arrest; Humans; Vasopressins

Topics: Epinephrine; Heart Arrest; Humans; Patient Discharge; Vasopressins

So far, there remains a controversy regarding the efficacy of epinephrine (Ep) in patients with cardiopulmonary arrest (CPA). In this study, we evaluated the importance of the plasma levels of catecholamines prior to the administration of Ep in patients with CPA. Patients with out-of-hospital cardiac arrest (OHCA) who were transferred to Gunma University Hospital were enrolled prospectively between July 2014 and July 2017. The levels of catecholamines [Ep, norepinephrine (NEp), and dopamine] and vasopressin (antidiuretic hormone) in the plasma were measured using blood samples of cardiogenic patients with OHCA not treated with Ep. Patients were divided into two groups: the return of spontaneous circulation [ROSC (+) ] group and the no return of spontaneous circulation [ROSC (-) ] group. The plasma levels of these agents and the conditions of resuscitation were compared between these two groups. 48 patients with cardiogenic CPA had not been treated with Ep prior to obtaining the blood samples. The ROSC (+) and ROSC (-) groups included 14 and 34 patients, respectively. The frequency of prehospital defibrillation was significantly higher in the ROSC (+) group. However, the prehospital resuscitation time was significantly shorter in the ROSC (+) group. Moreover, the levels of Ep and NEp in the plasma were significantly lower in the ROSC (+) group. The increased levels of Ep in the plasma may not be associated with the acquisition of ROSC in patients with cardiogenic CPA.

Topics: Aged; Aged, 80 and over; Biomarkers; Cardiopulmonary Resuscitation; Catecholamines; Emergency Medical Services; Epinephrine; Female; Follow-Up Studies; Heart Arrest; Humans; Male; Prognosis; Prospective Studies; Time Factors; Vasopressins

Topics: Adult; Atropine; Blood Loss, Surgical; Drug Combinations; Epinephrine; Female; Heart Arrest; Hemostatics; Humans; Injections, Intralesional; Uterine Myomectomy; Vasopressins

This case study describes a 25-year-old patient who had a witnessed cardiac arrest in the medical intensive care unit. The patient received 107 minutes of cardiopulmonary resuscitation before the veno-arterial extracorporeal membrane oxygenation was initiated. During extracorporeal life support, the patient's cardiac function improved. The patient was weaned from extracorporeal membrane oxygenation on day 6 and was discharged without physical and neurological complications on day 28. The successful resuscitation in this case attributed to high-quality CCPR and timely ECMO support.

Topics: Adult; Blood Pressure; Cardiopulmonary Resuscitation; Epinephrine; Extracorporeal Membrane Oxygenation; Heart Arrest; Humans; Male; Vasopressins

Low-dose steroids may reduce the mortality of severely ill patients with septic shock. We sought to determine whether exposure to stress-dose steroids during and/or after cardiopulmonary resuscitation is associated with reduced risk of death due to postresuscitation septic shock.. We analyzed pooled, individual patient data from two prior, randomized clinical trials (RCTs). RCTs evaluated vasopressin, steroids, and epinephrine (VSE) during resuscitation and stress-dose steroids after resuscitation in vasopressor-requiring, in-hospital cardiac arrest. In the second RCT, 15 control group patients received open-label, stress-dose steroids. Patients with postresuscitation shock were assigned to a Steroids (n = 118) or No Steroids (n = 73) group according to an "as-treated" principle. We used cumulative incidence competing risks Cox regression to determine cause-specific hazard ratios (CSHRs) for pre-specified predictors of lethal septic shock (primary outcome). In sensitivity analyses, data were analyzed according to the intention-to-treat (ITT) principle (VSE group, n = 103; control group, n = 88).. Lethal septic shock was less likely in Steroids versus No Steroids group, CSHR, 0.40, 95% confidence interval (CI), 0.20-0.82; p = 0.012. ITT analysis yielded similar results: VSE versus Control, CSHR, 0.44, 95% CI, 0.23-0.87; p = 0.019. Adjustment for significant, between-group baseline differences in composite cardiac arrest causes such as "hypotension and/or myocardial ischemia" did not appreciably affect the aforementioned CSHRs.. In this reanalysis, exposure to stress-dose steroids (primarily in the context of a combined VSE intervention) was associated with lower risk of postresuscitation lethal septic shock.

Topics: Aged; Cardiopulmonary Resuscitation; Drug Combinations; Epinephrine; Female; Heart Arrest; Humans; Male; Middle Aged; Patient Admission; Protective Factors; Randomized Controlled Trials as Topic; Retrospective Studies; Risk Factors; Shock, Septic; Steroids; Time Factors; Treatment Outcome; Vasopressins

Vasopressin is a locally-injected vasoconstrictor used to reduce bleeding during gynaecological surgery. However, even in these cases, vasopressin can induce adverse effects, including bradycardia, myocardial infarction and cardiac arrest. Elevated blood concentrations of vasopressin may induce the sympathoinhibitory reflex by increasing blood pressure and augment the sympathoinhibitory reflex by activating the area postrema. In addition, pneumoperitoneum formation needed for laparoscopy as well as physiological changes caused by steep Trendelenburg positions used during robotic surgeries may cause bradycardia. Shoulder braces used to prevent slipping from a steep Trendelenburg position may also be hazardous. This case report describes a 31-year-old female patient who underwent a scheduled robotic-assisted laparoscopic myomectomy in a steep Trendelenburg position. The patient experienced a cardiac arrest 2 min after the vasopressin injection and was treated accordingly. There were no abnormal findings on the postoperative laboratory studies, chest X-ray and electrocardiogram. The patient also had clear consciousness with no other notable symptoms. The patient was discharged on postoperative day 2. The report discusses the potential adverse effects of local vasopressin injection during robotic-assisted laparoscopic myomectomy.

Topics: Adult; Female; Gynecologic Surgical Procedures; Heart Arrest; Humans; Injections, Intramuscular; Laparoscopy; Leiomyoma; Robotic Surgical Procedures; Uterine Myomectomy; Uterine Neoplasms; Vasopressins

To investigate the feasibility of a refined aortic flush catheter and pump system to induce emergency preservation and resuscitation before extracorporeal cardiopulmonary resuscitation in a normovolemic cardiac arrest swine model simulating near real size/weight conditions of adults.. In this feasibility study, 8 female Large White breed pigs weighing 70 to 80 kg underwent ventricular fibrillation cardiac arrest for 15 minutes, followed by 4°C aortic flush (150 mL/kg for the brain; 50 mL/kg for the spine) via a new hardware ensued by resuscitation with extracorporeal cardiopulmonary resuscitation.. Brain temperature was lowered from 39.9°C (interquartile range [IQR] 39.6-40.3) to 24.0°C (IQR 20.8-28.9) in 12 minutes (IQR 11-16) with a median cooling rate of 1.3°C (IQR 0.7-1.6) per minute. A median of 776 mL (IQR 673-840) per minute with a median pump pressure of 1487 mm Hg (IQR 1324-1545) were pumped to the brain.. With the new hardware, we were able to cool the brain within a few minutes in a large pig cardiac arrest model. The exact position; the design, diameter, and length of the flush catheter; and the brain perfusion pressure seem to be critical to effectively reduce brain temperature. Redistribution of peripheral blood could lead to sterile inflammation again and might be avoided.

Topics: Animals; Aorta; Body Temperature; Brain Ischemia; Catheters; Epinephrine; Equipment Design; Extracorporeal Membrane Oxygenation; Feasibility Studies; Heart Arrest; Heparin; Hypothermia, Induced; Infusions, Intra-Arterial; Models, Animal; Resuscitation; Sodium Chloride; Swine; Vasopressins

Anesthesia for lung transplantation remains one of the highest risk surgeries in the domain of the cardiothoracic anesthesiologist. End-stage lung disease, pulmonary hypertension, and right heart dysfunction as well as other comorbid disease factors predispose the patient to cardiovascular, respiratory and metabolic dysfunction during general anesthesia. Perhaps the highest risk phase of surgery in the patient with severe pulmonary hypertension is during the induction of anesthesia when the removal of intrinsic sympathetic tone and onset of positive pressure ventilation can decompensate a severely compromised cardiovascular system. Severe hypotension, cardiac arrest, and death have been reported previously. Here we present 2 high-risk patients for lung transplantation, their anesthetic induction course, and outcomes. We offer suggestions for the safe management of anesthetic induction to mitigate against hemodynamic and respiratory complications.

Topics: Adrenergic alpha-Agonists; Anesthesia; Bronchodilator Agents; Calcium Chloride; Cardiopulmonary Resuscitation; Cardiotonic Agents; Epinephrine; Fatal Outcome; Female; Heart Arrest; Humans; Hypertension, Pulmonary; Lung Transplantation; Male; Middle Aged; Milrinone; Nitric Oxide; Norepinephrine; Sodium Bicarbonate; Vasoconstrictor Agents; Vasopressins

Case report.. Operating room.. 25YF, ASA IV E who underwent an emergent decompressive craniectomy for refractory intracranial hypertension secondary to acute intracranial hemorhage.. A 25Y caucasian female presented with acute intracranial hemorrhage with intraventricular extension secondary to Moya Moya disease. Post admisison, she underwent an emergent decompressive craniectomy for medically refractory intracranial hypertension. Introperatively (post dural closure and bone flap removal) the patient developed acutely worsening peak and plateau pressures followed by pulseless electrical activity necessitating CPR with epinephrine and Vasopressin before return of circulation before return of circulation. Intraoperative TEE done during return of circulation, was essentially non diagnostic, the patient had normal breath sounds throughout, and non-contributory bronchoscopy findings.. EKG, arterial blood pressure, heart rate, resp. rate, introperative tranesophageal echocardiogram (TEE), Pulse oximetry, serial arterial blood gases, introperative bronchoscopy, ventilatory peak pressures.. A post operative chest CT revealed extensive pneumomediastinum with subcutaneous emphysema. The focussed introperative echocardiogram showed preserved left ventricular function and no evidence of tamponade physiology.. Tension pneumomediastinum was the likely etiologic factor for the acute hemodynamic collapse and should be considered in the differential diagnosis of intraoperative circulatory arrest.

Topics: Adult; Angiography; Bronchoscopy; Cardiopulmonary Resuscitation; Chest Tubes; Computed Tomography Angiography; Decompressive Craniectomy; Diagnosis, Differential; Echocardiography, Transesophageal; Epinephrine; Female; Heart Arrest; Humans; Intracranial Hemorrhages; Intracranial Hypertension; Intraoperative Complications; Mediastinal Emphysema; Moyamoya Disease; Pulmonary Embolism; Respiratory Sounds; Vasoconstrictor Agents; Vasopressins

This study compared the effects of vasopressin via tibial intraosseous (IO) and intravenous (IV) routes on maximum plasma concentration (Cmax), the time to maximum concentration (Tmax), return of spontaneous circulation (ROSC), and time to ROSC in a hypovolemic cardiac arrest model.. This study was a randomized prospective, between-subjects experimental design. A computer program randomly assigned 28 Yorkshire swine to one of four groups: IV (n=7), IO tibia (n=7), cardiopulmonary resuscitation (CPR) + defibrillation (n=7), and a control group that received just CPR (n=7). Ventricular fibrillation was induced, and subjects remained in arrest for two minutes. CPR was initiated and 40 units of vasopressin were administered via IO or IV routes. Blood samples were collected at 0.5, 1, 1.5, 2, 2.5, 3, and 4 minutes. CPR and defibrillation were initiated for 20 minutes or until ROSC was achieved. We measured vasopressin concentrations using high-performance liquid chromatography.. There was no significant difference between the IO and IV groups relative to achieving ROSC (p=1.0) but a significant difference between the IV compared to the CPR+ defibrillation group (p=0.031) and IV compared to the CPR-only group (p=0.001). There was a significant difference between the IO group compared to the CPR+ defibrillation group (p=0.031) and IO compared to the CPR-only group (p=0.001). There was no significant difference between the CPR + defibrillation group and the CPR group (p=0.127). There was no significant difference in Cmax between the IO and IV groups (p=0.079). The mean ± standard deviation of Cmax of the IO group was 58,709±25, 463 pg/mL compared to the IV group, which was 106,198±62, 135 pg/mL. There was no significant difference in mean Tmax between the groups (p=0.084). There were no significant differences in odds of ROSC between the tibial IO and IV groups.. Prompt access to the vascular system using the IO route can circumvent the interruption in treatment observed with attempting conventional IV access. The IO route is an effective modality for the treatment of hypovolemic cardiac arrest and may be considered first line for rapid vascular access.

Topics: Animals; Cardiopulmonary Resuscitation; Disease Models, Animal; Electric Countershock; Heart Arrest; Hypovolemia; Infusions, Intraosseous; Infusions, Intravenous; Male; Random Allocation; Swine; Vasoconstrictor Agents; Vasopressins

The aim of this study was to investigate the effects of different treatment combinations on bupropion recovery as well as time to return of spontaneous circulation.. We conducted an eight group, randomized, experiment to evaluate combinations of epinephrine, vasopressin, and lipids on the restoration of cardiac function in Yorkshire pigs. After tracking the animals' baseline vitals for 10 minutes, we injected the animals with bupropion (35 mg/kg) and initiated a randomized protocol 2 minutes after cardiac arrest.. Results demonstrated that animal survival given treatment combinations including epinephrine were statistically superior to any other group (p < 0.001, Fishers' exact test). The odds of survival with use of epinephrine vs. other options were 22:1 (5.47, 88.43). Further, all animals receiving only lipids died. Cox survival analysis with bootstrapped parameter estimates provided evidence that the rapidity of cardiac recovery was maximized with a combination of epinephrine and lipids (p < 0.05).. Lipids may require an additional chemical catalyst in order to be effective in cardiac recovery. Epinephrine and lipids combined shortened recovery time for surviving animals.

Topics: Animals; Bupropion; Cardiopulmonary Resuscitation; Drug Overdose; Epinephrine; Fat Emulsions, Intravenous; Heart Arrest; Humans; Models, Animal; Prospective Studies; Swine; Vasopressins

Compare vasopressin, amiodarone, and epinephrine administration by sternal intraosseous (SIO), tibial intraosseous (TIO), and intravenous (IV) routes in a swine model of cardiac arrest.. Prospective, randomized, between subjects, experimental design.. Laboratory.. Male Yorkshire-cross swine (N = 35), seven per group.. Swine were randomized to SIO, TIO, IV, cardiopulmonary resuscitation (CPR) with defibrillation, or CPR-only groups. Ventricular fibrillation (VF) was induced under general anesthesia. Mechanical CPR began 2 minutes postarrest. Vasopressin (40 U) was administered to the SIO, TIO, and IV groups 4 minutes postarrest. Defibrillation was performed and amiodarone (300 mg) was administered 6 minutes postarrest. Defibrillation was repeated, and epinephrine (1 mg) was administered 10 minutes postarrest. Defibrillation was repeated every 2 minutes and epinephrine repeated every 4 minutes until return of spontaneous circulation (ROSC) or 26 postarrest minutes elapsed.. Rate of ROSC, time to ROSC, and odds of ROSC.. There were no significant differences in rate of ROSC between the SIO and TIO (p = 0.22) or IV groups (p = 1.0). Time to ROSC was five times less in the SIO group than the TIO group (p = 0.003) but not compared to IV (p = 0.125). Time to ROSC in the IV group was significantly less than the TIO group (p = 0.04). Odds of ROSC for the SIO group were five times higher compared to the TIO group but same as IV. Odds of ROSC in the IV group were higher than the TIO group.. There was a statistically significant delay in the time to ROSC and a clinically significant difference in odds of ROSC when resuscitative drugs, including lipophilic amiodarone, were administered by the TIO route compared to the SIO and IV routes in a swine model of sudden cardiac arrest. Further investigations are warranted to isolate the mechanism behind these findings.

Topics: Administration, Intravenous; Amiodarone; Animals; Anti-Arrhythmia Agents; Cardiopulmonary Resuscitation; Disease Models, Animal; Electric Countershock; Epinephrine; Heart Arrest; Infusions, Intraosseous; Male; Prospective Studies; Random Allocation; Sternum; Sus scrofa; Swine; Tibia; Time Factors; Treatment Outcome; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

Purposes of this study were to compare intravenous (IV) and sternal intraosseous (SIO) administration of vasopressin relative to concentration maximum (Cmax), time to maximum concentration (Tmax), and mean concentration in a cardiac arrest model.. Prospective, between subjects, randomized experimental design.. Vivarium.. Yorkshire-cross swine (N = 16) INTERVENTION: Swine were anesthetized, placed into cardiac arrest, and after 2 minutes, cardiopulmonary resuscitation was initiated. After additional 2 minutes, 40 units of vasopressin was administered either by SIO or IV route. Blood samples were collected over 4 minutes. Cmax and means were analyzed using high-performance liquid chromatography tandem mass spectrometry.. Cmax, Tmax, and mean plasma concentrations.. There were no significant differences in the SIO and IV groups in Cmax (p = 0.96) or Tmax (p = 0.27). The IV and SIO group had a mean Cmax of 68,151 ± SD 21,534 and 69,034 ± SD 40,169 pg/mL, respectively. The IV and SIO vasopressin groups had a mean Tmax of 105 ± SD 39 and 80 ± SD 41 seconds, respectively.. A multivariate analyses of variance indicated that there were no statistically significant differences in pretest data, Cmax, and Tmax; a repeated analyses of variance indicated that there were no significant differences between the groups relative to mean concentrations of serum vasopressin over time (p > 0.05).. When a patient is in cardiac arrest, it is essential to establish rapid and reliable access to blood vessels so that life-saving drugs can be administered and the SIO provides such a route.

Topics: Animals; Cardiopulmonary Resuscitation; Chromatography, High Pressure Liquid; Disease Models, Animal; Heart Arrest; Infusions, Intraosseous; Infusions, Intravenous; Male; Multivariate Analysis; Prospective Studies; Random Allocation; Sternum; Sus scrofa; Swine; Tandem Mass Spectrometry; Vasoconstrictor Agents; Vasopressins

Compare maximum concentration (Cmax), time to maximum concentration (Tmax), mean serum concentration of vasopressin, return of spontaneous circulation (ROSC), time to ROSC, and odds of survival relative to vasopressin administration by tibial intraosseous (TIO), humerus intraosseous (HIO), and intravenous (IV) routes in a hypovolemic cardiac arrest model.. Prospective, between subjects, randomized experimental design.. TriService Research Facility.. Yorkshire-cross swine (n = 40).. Swine were anesthetized, exsanguinated to a Class III hemorrhage, and placed into cardiac arrest. After 2 minutes, cardiopulmonary resuscitation was initiated. After an additional 2 minutes, a dose of 40 units of vasopressin was administered by TIO, HIO, or the IV routes. Blood samples were collected over 4 minutes and analyzed by high-performance liquid chromatography tandem mass spectrometry.. ROSC, time to ROSC, Cmax, Tmax, mean concentrations over time, and odds ratio.. There was no significant difference in rate of ROSC or time to ROSC between the TIO, HIO, and IV groups (p > 0.05). The Cmax was significantly higher in the IV group compared to the TIO group (p = 0.015), but no significant difference between the TIO versus HIO or HIO versus IV groups (p > 0.05). The Tmax was significantly shorter for the HIO compared to the TIO group (p = 0.034), but no significant differences between the IV group compared to the TIO or HIO groups (p > 0.05). The odds of survival were higher in the HIO group compared to all other groups.. The TIO and HIO provide rapid and reliable access to administer life-saving medications during cardiac arrest.

Topics: Animals; Cardiopulmonary Resuscitation; Disease Models, Animal; Electric Countershock; Heart Arrest; Humerus; Infusions, Intraosseous; Infusions, Intravenous; Male; Prospective Studies; Random Allocation; Shock, Hemorrhagic; Sus scrofa; Swine; Tibia; Time Factors; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

The American Heart Association (AHA) recommends intravenous (IV) or intraosseous (IO) vasopressin in Advanced Cardiac Life Support (ACLS). Obtaining IV access in hypovolemic cardiac arrest patients can be difficult, and IO access is often obtained in these life threatening situations. No studies have been conducted to determine the effects of humeral IO (HIO) access with vasopressin in the return of spontaneous circulation (ROSC). Our study compared the kinetics of vasopressin and ROSC with HIO with IV access in the hypovolemic swine model.. Twenty-two Yorkshire swine were divided into three groups: HIO (n = 7), IV (n = 8), and a control group (n = 7). The IV and HIO group received vasopressin and cardiopulmonary resuscitation (CPR), while the control group received only CPR. All subjects were exsanguinated 31 percent of their blood volume, placed in cardiac arrest, and resuscitated per ACLS. Subjects that achieved ROSC were then monitored for 20 minutes. Blood samples (10 mL) collected at 0.5, 1, 1.5, 2, 2.5, 3, and 4 minutes after vasopressin injection and analyzed for maximum concentration (Cmax) and time to maximum concentration (Tmax). Data were analyzed using a multivariate analysis of variance (MANOVA) and a Fisher's Exact Test.. ROSC was achieved in every subject that received vasopressin via the HIO route. Data analysis using a MANOVA pairwise comparison revealed no difference between mean Cmax (p = 0.601) and Tmax (p = 0.771) of vasopressin administered IV versus HIO routes. Analysis of the mean serum concentrations at time intervals using a repeated measures analysis of variance found no difference (p > 0.05). A Fisher's Exact Test revealed no difference in rate of ROSC between HIO and IV groups (p > 0.05). Odds ratio determined that there was a 33 times higher chance of survival among HIO subjects versus control (CPR and Defibrillation; p = 0.03) and no difference in the survivability of the HIO or IV groups (p = 0.52).. The data from this study strongly suggest that there is no significant difference in ROSC, time to ROSC, hemodynamics, or pharmacokinetics between HIO vasopressin and IV vasopressin. This research reinforces current AHA guidelines recommending the use of HIO route early over delaying care awaiting IV access.

Topics: Animals; Cardiopulmonary Resuscitation; Disease Models, Animal; Heart Arrest; Hypovolemia; Infusions, Intraosseous; Infusions, Intravenous; Male; Random Allocation; Swine; Vasoconstrictor Agents; Vasopressins

A recent commentary, "Resuscitation That's (Un)Shockable: Time to Get the Adrenaline Flowing", published in the New England Journal of Medicine Journal Watch called attention to a relatively recent study showing that a large and increasing percentage of patients with in-hospital cardiac arrests exhibit initial nonshockable rhythms (asystole or pulseless electrical activity [PEA]; 82% in 2009 vs 69% in 2000) and a most recent study that concluded that neurologically intact survival to hospital discharge after in-hospital cardiac arrest was significantly more likely after earlier epinephrine administration. It was found that delayed administration of epinephrine was associated significantly with lower chance for survival to hospital discharge, in stepwise fashion (12%, 10%, 8%, and 7% survival, respectively, for patients receiving their first epinephrine dose≤3, 4-6, 7-9, and >9 minutes after arrest). Although early use of epinephrine to manage patients with nonshockable rhythms lacks strong evidence to support efficacy, focus on time to epinephrine administration-in addition to high-quality chest compressions-might be the best early intervention. However, evidence may strongly support the recommendation that adrenaline needs to be used very early because without effective-depth cardiopulmonary resuscitation (CPR) with complete recoil, epinephrine may only be effective when gasping is present, which is a time-limited phenomenon. However, because very few rescuers can perform effective-depth chest compressions with complete recoil, gasping is critically necessary for adequate ventilation and generation of adequate coronary and cerebral perfusion. However, under acidemic conditions and high catecholamine levels and/or absence of gasping, vasopressin should be administered instead.

Topics: Cardiopulmonary Resuscitation; Dyspnea; Epinephrine; Heart Arrest; Heart Massage; Humans; Vasopressins

Our aim was to investigate cerebral and cardiac tissue injury subsequent to use of vasopressin and adrenaline in combination compared with vasopressin alone during cardiopulmonary resuscitation (CPR).. In a randomized, prospective, laboratory animal study 28 anesthetized piglets were subject to a 12-min untreated cardiac arrest and subsequent CPR. After 1 min of CPR, 10 of the piglets received 0.4 U/kg of arg(8)-vasopressin (V group), and 10 piglets received 0.4 U/kg of arg(8)-vasopressin, 1 min later followed by 20 µg/kg body weight of adrenaline, and another 1 min later continuous administration (10 µg/kg/min) of adrenaline (VA group). After 8 min of CPR, the piglets were defibrillated and monitored for another 3 h. Then they were killed and the brain immediately removed pending histological analysis.. During CPR, the VA group had higher mean blood pressure and cerebral cortical blood flow (CCBF) but similar coronary perfusion pressure. After restoration of spontaneous circulation there was no difference in the pressure variables, but CCBF tended to be (36% ± 16%) higher in the V group. Neuronal injury and signs of a disrupted blood-brain barrier (BBB) were greater, 20% ± 4% and 21% ± 4%, respectively, in the VA group. In a background study of repeated single doses of adrenaline every third minute after 5 min arrest but otherwise the same protocol, histological measurements showed even worse neural injury and disruption of the BBB.. Combined use of vasopressin and adrenaline caused greater signs of cerebral and cardiac injury than use of vasopressin alone during experimental cardiopulmonary resuscitation.

Topics: Animals; Blood Pressure; Blood-Brain Barrier; Cardiopulmonary Resuscitation; Central Nervous System; Cerebrovascular Circulation; Epinephrine; Heart Arrest; Perfusion; Pressure; Prospective Studies; Random Allocation; Swine; Time Factors; Vasopressins

Long-term survival after cardiac arrest (CA) due to shock-refractory ventricular fibrillation (VF) is low. Clearly, there is a need for new pharmacological interventions in the setting of cardiopulmonary resuscitation (CPR) to improve outcome. Here, hemodynamic parameters and cardiac damage are compared between the treatment group (milrinone, esmolol and vasopressin) and controls (vasopressin only) during resuscitation from prolonged CA in piglets.. A total of 26 immature male piglets were subjected to 12-min VF followed by 8-min CPR. The treatment group (n=13) received i.v. (intravenous) boluses vasopressin 0.4 U/kg, esmolol 250 μg/kg and milrinone 25 μg/kg after 13 min, followed by i.v. boluses esmolol 375 μg/kg and milrinone 25 μg/kg after 18 min and continuous esmolol 15 μg/kg/h infusion during 180 min reperfusion, whereas controls (n=13) received equal amounts of vasopressin and saline. A 200 J monophasic counter-shock was delivered to achieve resumption of spontaneous circulation (ROSC) after 8 min CPR. If ROSC was not achieved, another 200 J defibrillation and bolus vasopressin 0.4 U/kg would be administered in both groups. Direct current shocks at 360 J were applied as one shot per minute over maximally 5 min. Hemodynamic variables and troponin I as a marker of cardiac injury were recorded.. Troponin I levels after 180 min reperfusion were lower in the treatment group than in controls (P<0.05). The treatment group received less norepinephrine (P<0.01) and had greater diuresis (P<0.01). There was no difference in survival between groups.. The combination of milrinone, esmolol and vasopressin decreased cardiac injury compared with vasopressin alone.

Topics: Acid-Base Equilibrium; Adrenergic beta-Antagonists; Animals; Cardiopulmonary Resuscitation; Cardiotonic Agents; Fluid Therapy; Heart Arrest; Heart Diseases; Male; Milrinone; Myocardium; Propanolamines; Survival Analysis; Swine; Troponin I; Vasoconstrictor Agents; Vasopressins

Topics: Cardiopulmonary Resuscitation; Catecholamines; Cell Movement; Epinephrine; Heart Arrest; Humans; Leukocytes; Vasopressins

Hypothermia is recommended by international guidelines for treatment of unconscious survivors of cardiac arrest to improve neurologic outcomes. However, temperature management is often underutilized because it may be difficult to implement. The present study evaluated the efficacy of pharmacologically induced hypothermia on survival and neurological outcome in rats resuscitated from cardiac arrest.. Cardiac arrest was induced for 10 min in 120 rats. Sixty-one rats were resuscitated and randomized to normothermia, physical cooling or pharmacological hypothermia 5 min after resuscitation. Pharmacological hypothermia rats received a combination of ethanol, vasopressin and lidocaine (HBN-1). Physical hypothermia rats were cooled with intravenous iced saline and cooling pads. Rats in the pharmacological hypothermia group received HBN-1 at ambient temperature (20 °C). Normothermic rats were maintained at 37.3 ± 0.2 °C.. HBN-1 (p < 0.0001) shortened the time (85 ± 71 min) to target temperature (33.5 °C) versus physical hypothermia (247 ± 142 min). The duration of hypothermia was 17.0 ± 6.8h in the HBN-1 group and 17.3 ± 7.5h in the physical hypothermia group (p = 0.918). Survival (p = 0.034), neurological deficit scores (p < 0.0001) and Morris Water Maze performance after resuscitation (p = 0.041) was improved in the HBN-1 versus the normothermic group. HBN-1 improved survival and early neurological outcome compared to the physical hypothermia group while there was no significant difference in performance in the Morris water maze.. HBN-1 induced rapid and prolonged hypothermia improved survival with good neurological outcomes after cardiac arrest suggesting that pharmacologically induced regulated hypothermia may provide a practical alternative to physical cooling.

Topics: Anesthetics, Local; Animals; Body Temperature; Cardiopulmonary Resuscitation; Disease Models, Animal; Drug Combinations; Ethanol; Female; Heart Arrest; Hypothermia, Induced; Lidocaine; Rats; Rats, Sprague-Dawley; Vasoconstrictor Agents; Vasopressins

Ventilation through an impedance threshold device (ITD) purportedly improves hemodynamics and survivability and is given a Class IIb recommendation by the American Heart Association/American College of Cardiology for adult cardiac arrest. No studies have investigated the effects of an ITD with vasopressin.. This study compared return of spontaneous circulation (ROSC), time to ROSC, hemodynamics, and pharmacokinetics with and without the use of a ResQPOD ITD. Swine were randomized to three groups: cardiopulmonary resuscitation and defibrillation alone, vasopressin with ResQPOD, and vasopressin without ResQPOD. Survival differences between the cardiopulmonary resuscitation and defibrillation group versus with and without ResQPOD groups were found (p = 0.001, FET; p = 0.021, FET, respectively) but no differences between with and without ResQPOD groups (p = 0.462). A test of Cmax between the IV and IV/ResQPOD group provided limited evidence that the IV/ResQPOD group attained higher Cmax than then IV only group (U = 11.00, p = 0.097). Median Tmax and ROSC were not statistically different between the groups (U = 11.00, p = 0.314).. Our data suggest that there is no difference in drug kinetics or clinical outcomes in terms of survivability with or without the ResQPOD.

Topics: Animals; Cardiopulmonary Resuscitation; Disease Models, Animal; Electric Countershock; Heart Arrest; Hemodynamics; Male; Random Allocation; Survival Rate; Swine; Vasoconstrictor Agents; Vasopressins

Adrenaline (ADR) and vasopressin (VAS) are used as vasopressors during cardiopulmonary resuscitation. Data regarding their effects on blood-brain barrier (BBB) integrity and neuronal damage are lacking. We hypothesised that VAS given during cardiopulmonary resuscitation (CPR) after haemorrhagic circulatory arrest will preserve BBB integrity better than ADR.. Twenty-one anaesthetised sexually immature male piglets (with a weight of 24.3 ± 1.3 kg) were bled 35% via femoral artery to a mean arterial blood pressure of 25 mmHg in the period of 15 min. Afterwards, the piglets were subjected to 8 min of untreated ventricular fibrillation followed by 15 min of open-chest CPR. At 9 min of circulatory arrest, piglets received amiodarone 1.0 mg/kg and hypertonic-hyperoncotic solution 4 ml/kg infusions for 20 min. At the same time, VAS 0.4 U/kg was given intravenously to the VAS group (n = 9) while the ADR group received ADR 20 μg/kg (n = 12). Internal defibrillation was attempted from 11 min of cardiac arrest to achieve restoration of spontaneous circulation. The experiment was terminated 3 h after resuscitation.. The intracranial pressure (ICP) in the post-resuscitation phase was significantly greater in ADR group than in VAS group. VAS group piglets exhibited a significantly smaller BBB disruption compared with ADR group. Cerebral pressure reactivity index showed that cerebral blood flow autoregulation was also better preserved in VAS group.. Resuscitation with ADR as compared with VAS after haemorrhagic circulatory arrest increased the ICP and impaired cerebrovascular autoregulation more profoundly, as well as exerted an increased BBB disruption though no significant difference in neuronal injury was observed.

Topics: Amiodarone; Animals; Blood-Brain Barrier; Capillary Permeability; Cardiopulmonary Resuscitation; Cerebrovascular Circulation; Dobutamine; Electric Countershock; Enzyme Activation; Epinephrine; Fluid Therapy; Heart Arrest; Hemodynamics; Hemorrhage; Intracranial Pressure; Male; Nitric Oxide Synthase Type I; Nitric Oxide Synthase Type II; Sus scrofa; Swine; Vasopressins; Ventricular Fibrillation

Epinephrine is a component of all resuscitation algorithms. Vasopressin is a pulmonary vasodilator and systemic vasopressor. We investigated the effect of epinephrine vs. vasopressin on survival and hemodynamics after neonatal porcine cardiac arrest (CA).. A 4-min asphyxial CA was induced, after which cardiopulmonary resuscitation (CPR) was commenced. Animals were randomized to low- (LDE: 0.01 mg/kg) or high-dose epinephrine (HDE: 0.03 mg/kg), low- (LDV: 0.2 U/kg) or high-dose vasopressin (HDV: 0.4 U/kg), or control (saline). Clinical and echocardiography indexes were monitored.. Sixty-nine animals were randomized. Survival was greater in HDV (n = 8 (89%); P < 0.05 ANOVA) vs. control (n = 7 (43%)) and LDE (n = 5 (36%)) but not vs. HDE (n = 7 (64%)) or LDV (n = 6 (75%)). Animals resuscitated with LDE required more shocks (2.5 (interquartile range: 2-6); P < 0.05) and higher doses of energy (15 J (interquartile range: 10-20); P < 0.05). Left ventricular output was comparable between groups, but a greater increase in superior vena caval flow was seen after HDV (P < 0.001 vs. control, LDE, and HDE). Plasma troponin was greatest in the HDE group (P < 0.05 vs. control and HDV).. Vasopressin results in improved survival, lower postresuscitation troponin, and less hemodynamic compromise after CA in newborn piglets. Vasopressin may be a candidate for testing in human neonates.

Topics: Analysis of Variance; Animals; Animals, Newborn; Cardiopulmonary Resuscitation; Dose-Response Relationship, Drug; Echocardiography; Epinephrine; Heart Arrest; Swine; Treatment Outcome; Troponin; Vasopressins

Topics: Early Detection of Cancer; Evidence-Based Medicine; Glucocorticoids; Heart Arrest; Humans; Hypothermia, Induced; Lung Neoplasms; Neoplasm Staging; Predictive Value of Tests; Prevalence; Radiography, Thoracic; Sensitivity and Specificity; Tomography, X-Ray Computed; Treatment Outcome; United States; Vasoconstrictor Agents; Vasopressins

Supplemental digital content is available in the text.. The aim of this experimental study was to compare survival and hemodynamic effects of a low-dose amiodarone and vasopressin compared with vasopressin in hypovolemic cardiac arrest model in piglets.. Eighteen anesthetized male piglets (with a weight of 25.3 [1.8] kg) were bled approximately 30% of the total blood volume via the femoral artery to a mean arterial blood pressure of 35 mm Hg in a 15-minute period. Afterward, the piglets were subjected to 4 minutes of untreated ventricular fibrillation followed by 11 minutes of open-chest cardiopulmonary resuscitation. At 5 minutes, circulatory arrest amiodarone 1 mg/kg was intravenously administered in the amiodarone group (n = 9), while the control group received the same amount of saline (n = 9). At the same time, all piglets received vasopressin 0.4 U/kg intravenously administered and hypertonic-hyperoncotic solution 3-mL/kg infusion for 20 minutes. Internal defibrillation was attempted from 7 minutes of cardiac arrest to achieve restoration of spontaneous circulation. The experiment was terminated 3 hours after resuscitation.. Three-hour survival was greater in the amiodarone group (p = 0.02). After the successful resuscitation, the amiodarone group piglets had significantly lower heart rate as well as greater systolic, diastolic, and mean arterial pressure. Troponin I plasma concentrations were lower and urine output was greater in the amiodarone group.. Combined resuscitation with amiodarone and vasopressin after hemorrhagic circulatory arrest resulted in greater 3-hour survival, better preserved hemodynamic parameters, and smaller myocardial injury compared with resuscitation with vasopressin only.

Topics: Amiodarone; Animals; Antidiuretic Agents; Disease Models, Animal; Dose-Response Relationship, Drug; Drug Therapy, Combination; Heart Arrest; Hemodynamics; Hemorrhage; Injections, Intravenous; Male; Resuscitation; Swine; Treatment Outcome; Vasodilator Agents; Vasopressins; Ventricular Fibrillation

Topics: Adrenergic beta-Agonists; Epinephrine; Female; Heart Arrest; Hemostatics; Humans; Male; Methylprednisolone; Neuroprotective Agents; Vasopressins

Vasopressin administration has been tested in cardiac arrest. However it has not been tested when cardiac arrest occurs in certain circumstances, as in sepsis, where it may have a major role. The aim of the study was to investigate survival after cardiac arrest in a septic porcine model compared with healthy animals and to explore the effectiveness of adding vasopressin vs epinephrine alone administration.. Thirty five healthy piglets of both genders were studied. The piglets were randomly assigned into three groups: group A (n = 8), group B (n = 14), group C (n = 13). Animals of groups B and C were given endotoxin to mimic a septic state before arrest. We applied the same resuscitation protocol to all pigs but we replaced the first dose of epinephrine with vasopressin in pigs of group C. Following surgical preparation and 30 min resting period, baseline measurements were recorded. In order to assess tissue oxygenation, we implemented Near Infrared Spectroscopy (NIRS) with the vascular occlusion technique (VOT) in thirteen lipopolysaccharide (LPS)-treated animals, occluding abdominal aorta and inferior vena cava. Afterwards, LPS (100 μg/kg) was infused in a 30 min period to animals of groups B and C and normal saline to group A. New NIRS measurements were obtained again. Subsequently, we provoked ventricular fibrillation (VF). After 3 min of untreated VF, open chest cardiopulmonary resuscitation (CPR) was performed manually. Primary end point was the restoration of spontaneous circulation (ROSC).. The chance of ROSC for the groups A, B and C was 75%, 35.7%, and 30.7% respectively. A significant difference in ROSC was established between septic (group B + C) and non septic piglets (group A) (P = 0.046). Vasopressin administration had no effect in outcome. LPS administration decreased oxygen consumption rate, as assessed by NIRS, in peripheral tissues (22.6 ± 7.2. vs 18.5 ± 7.2, P = 0.07).. Septic piglets have fewer chances to survive after cardiac arrest. No difference in outcome was observed when the first dose of epinephrine was replaced with vasopressin to treat cardiac arrest in the LPS-treated animals.

Topics: Animals; Epinephrine; Female; Heart Arrest; Lipopolysaccharides; Male; Resuscitation; Sepsis; Spectroscopy, Near-Infrared; Swine; Vasopressins

Topics: Anti-Inflammatory Agents; Cardiopulmonary Resuscitation; Controlled Clinical Trials as Topic; Drug Therapy, Combination; Epinephrine; Greece; Heart Arrest; Hospital Mortality; Hospitalization; Humans; Hydrocortisone; Methylprednisolone; Neurologic Examination; Shock, Cardiogenic; Survival Rate; Vasoconstrictor Agents; Vasopressins

Topics: Adrenergic beta-Agonists; Epinephrine; Female; Heart Arrest; Hemostatics; Humans; Male; Methylprednisolone; Neuroprotective Agents; Vasopressins

The effect of vasoconstrictors in prolonged cardiopulmonary resuscitation (CPR) has not been fully clarified.. To evaluate adrenaline and vasopressin pressure effect, and observe the return of spontaneous circulation (ROSC).. A prospective, randomized, blinded, and placebo-controlled study. After seven minutes of untreated ventricular fibrillation, pigs received two minutes cycles of CPR. Defibrillation was attempted (4 J/kg) once at 9 minutes, and after every cycle if a shockable rhythm was present, after what CPR was immediately resumed. At 9 minutes and every five minutes intervals, 0.02 mg/kg (n = 12 pigs) adrenaline, or 0.4 U/kg (n = 12) vasopressin, or 0.2 mL/kg (n = 8) 0.9% saline solution was administered. CPR continued for 30 minutes or until the ROSC.. Coronary perfusion pressure increased to about 20 mmHg in the three groups. Following vasoconstrictors doses, pressure level reached 35 mmHg versus 15 mmHg with placebo (p < 0.001). Vasopressin effect remained at 15-20 mmHg after three doses versus zero with adrenaline or placebo. ROSC rate differed (p = 0.031) among adrenaline (10/12), vasopressin (6/12), and placebo (2/8). Time-to-ROSC did not differ (16 minutes), nor the number of doses previously received (one or two). There was no difference between vasoconstrictors, but against placebo, only adrenaline significantly increased the ROSC rate (p = 0.019).. The vasoconstrictors initial pressure effect was equivalent and vasopressin maintained a late effect at prolonged resuscitation. Nevertheless, when compared with placebo, only adrenaline significantly increased the ROSC rate.

Topics: Animals; Cardiopulmonary Resuscitation; Disease Models, Animal; Double-Blind Method; Drug Evaluation, Preclinical; Epinephrine; Heart Arrest; Prospective Studies; Random Allocation; Swine; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

Topics: Adrenergic beta-Agonists; Epinephrine; Female; Heart Arrest; Hemostatics; Humans; Male; Methylprednisolone; Neuroprotective Agents; Vasopressins

Local anesthetic (LA) intoxication with cardiovascular arrest is a potential fatal complication of regional anesthesia. Lipid resuscitation has been recommended for the treatment of LA-induced cardiac arrest. Aim of the study was to compare four different rescue regimens using epinephrine and/or lipid emulsion and vasopressin to treat cardiac arrest caused by bupivacaine intoxication.. Twenty-eight piglets were randomized into four groups (4 × 7), anesthetized with sevoflurane, intubated, and ventilated. Bupivacaine was infused with a syringe driver via central venous catheter at a rate of 1 mg·kg(-1)·min(-1) until circulatory arrest. Bupivacaine infusion and sevoflurane were then stopped, chest compression was started, and the pigs were ventilated with 100% oxygen. After 1 min, epinephrine 10 μg·kg(-1) (group 1), Intralipid(®) 20% 4 ml·kg(-1) (group 2), epinephrine 10 μg·kg(-1) + Intralipid(®) 4 ml·kg(-1) (group 3) or 2 IU vasopressin + Intralipid(®) 4 ml·kg(-1) (group 4) were administered. Secondary epinephrine doses were given after 5 min if required.. Survival was 71%, 29%, 86%, and 57% in groups 1, 2, 3, and 4. Return of spontaneous circulation was regained only by initial administration of epinephrine alone or in combination with Intralipid(®). Piglets receiving the combination therapy survived without further epinephrine support. In contrast, in groups 2 and 4, return of spontaneous circulation was only achieved after secondary epinephrine rescue.. In cardiac arrest caused by bupivacaine intoxication, first-line rescue with epinephrine and epinephrine + Intralipid(®) was more effective with regard to survival than Intralipid(®) alone and vasopressin + Intralipid(®) in this pig model.

Topics: Anesthetics, Local; Animals; Blood Gas Analysis; Blood Pressure; Bupivacaine; Cardiopulmonary Resuscitation; Chromatography, High Pressure Liquid; Dose-Response Relationship, Drug; Electrocardiography; Emulsions; Epinephrine; Female; Heart Arrest; Male; Mass Spectrometry; Phospholipids; Soybean Oil; Survival Analysis; Swine; Tachycardia, Ventricular; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

To study the effects of the combination of adrenaline (epinephrine) and vasopressin compared to adrenaline alone on initial resuscitation success, 24h survival, and neurological outcome in a swine model of asphyxial cardiac arrest (CA).. This prospective randomized experimental study was conducted at a laboratory research department. Twenty female Landrace/Large-White pigs, 12-15 weeks of age, were investigated. Asphyxial CA was induced by clamping of the endotracheal tube. After 4min of untreated CA, resuscitation was initiated by unclamping the endotracheal tube, mechanical ventilation, chest compressions and adrenaline (Group A) or a combination of adrenaline with vasopressin (Group A+V) administered intravenously. In case of restoration of spontaneous circulation (ROSC), the animals were monitored for 30min and then observed for 24h.. Hemodynamic variables were measured at baseline during CPR and in the post-resuscitation period. Statistically significant difference was observed in groups A and A+V regarding coronary perfusion pressure (CPP) during the first minute of CPR. In both groups, ROSC and survival rates were comparable (p=NS). Neurological deficit score (NDS) was significantly higher in the combination group 24h following CA (p<0.001). Brain histological damage score (HDS) was also better in the combination group (p<0.001). Total HDS and NDS showed a statistical significant correlation (p<0.001).. In this porcine model of asphyxial CA, adrenaline alone as well as the combined administration of adrenaline and vasopressin resulted in similar ROSC and survival rates, but the combination of adrenaline and vasopressin resulted in improved neurological and cerebral histopathological outcomes.

Topics: Analysis of Variance; Animals; Asphyxia; Cardiopulmonary Resuscitation; Cerebrovascular Circulation; Combined Modality Therapy; Disease Models, Animal; Dose-Response Relationship, Drug; Drug Therapy, Combination; Epinephrine; Female; Heart Arrest; Hemodynamics; Infusions, Intravenous; Nervous System Diseases; Random Allocation; Recovery of Function; Reference Values; Risk Assessment; Survival Rate; Sus scrofa; Swine; Time Factors; Vasopressins

The aim of the present study was to assess whether the combination of epinephrine, vasopressin, and nitroglycerin would improve initial resuscitation success, 24-hour survival, and neurologic outcome compared with epinephrine alone in a swine model of asphyxial cardiac arrest (CA).. This prospective randomized experimental study was conducted at a laboratory research department. Twenty male Landrace/Large-White pigs 12 to 15 weeks of age were investigated. Asphyxial CA was induced by occlusion of the endotracheal tube. Pigs remained untreated for 4 minutes before attempting resuscitation by unclamping the endotracheal tube, mechanical ventilation, chest compressions, and epinephrine (group E) or a combination of epinephrine with vasopressin and nitroglycerin (group EVN) administered intravenously. In case of restoration of spontaneous circulation, the animals were supported for 30 minutes and then observed for 24 hours.. Coronary perfusion pressure and mean arterial pressure were significantly increased during cardiopulmonary resuscitation in group EVN. In both groups, restoration of spontaneous circulation and survival rates were comparable (P value, nonsignificant). At 24 hours after CA, neurologic deficit score was significantly better in animals treated with the combination pharmacotherapy (P < .001). Brain histologic damage score was also higher in group EVN compared with group E (P < .001). Total histologic damage score and neurologic deficit score showed a statistical significant correlation (P < .001).. In this porcine model of asphyxial CA, the addition of nitroglycerin to vasopressin and epinephrine maintained elevated coronary perfusion pressure during asphyxia CA and resulted in significantly better neurologic and histopathologic outcome in comparison with epinephrine alone.

Topics: Animals; Asphyxia; Blood Pressure; Brain; Cardiopulmonary Resuscitation; Drug Therapy, Combination; Epinephrine; Heart Arrest; Heart Rate; Hypoxia, Brain; Male; Nitroglycerin; Swine; Vasopressins

Topics: Advanced Cardiac Life Support; Cardiopulmonary Resuscitation; Emergency Service, Hospital; Heart Arrest; Humans; Research Design; Vasoconstrictor Agents; Vasopressins

Coronary perfusion pressure (CPP) during resuscitation from cardiac arrest has been shown to correlate with return of spontaneous circulation. Adrenergic blockade of beta-1 and alpha-1 receptors is common in the long-term management of ischemic heart disease and congestive heart failure. We sought to compare the CPP response to vasopressin vs. epinephrine in a swine model of cardiac arrest following pre-arrest adrenergic blockade.. Eight anesthetized and instrumented swine were administered 0.1mg epinephrine and arterial pressure and heart rate response were measured. An infusion of labetalol was then initiated and animals periodically challenged with epinephrine until adrenergic blockade was confirmed. The left anterior descending coronary artery was occluded to produce ventricular fibrillation (VF). After 7min of untreated VF, mechanical chest compressions were initiated. After 1min of compressions, 1mg epinephrine was given while CPP was recorded. When CPP values had returned to pre-epinephrine levels, 40U of bolus vasopressin was given. Differences in CPP (post-vasopressor-pre-vasopressor) were compared within animals for the epinephrine and vasopressin response and with eight, non-adrenergically blocked, historical controls using Bayesian statistics with a non-informative prior.. The CPP response following epinephrine was 15.1mmHg lower in adrenergically blocked animals compared to non-adrenergically blocked animals (95% Highest Posterior Density [HPD] 2.9-27.2mmHg lower). CPP went up 18.4mmHg more following vasopressin when compared to epinephrine (95% HPD 8.2-29.1mmHg). The posterior probability of a higher CPP response from vasopressin (vs. epinephrine) in these animals was 0.999.. Pre-arrest adrenergic blockade blunts the CPP response to epinephrine. Superior augmentation of CPP is attained with vasopressin under these conditions.

Topics: Adrenergic Antagonists; Animals; Blood Pressure; Coronary Circulation; Disease Models, Animal; Epinephrine; Heart Arrest; Heart Rate; Male; Swine; Vasopressins; Ventricular Fibrillation

In comparison to adrenaline, administration of vasopressin increases adrenal gland perfusion, but decreases catecholamine plasma concentrations when compared to saline placebo. We directly compared the effects of adrenaline with different doses of vasopressin on adrenal gland perfusion, and noradrenaline plasma concentrations during CPR.. Twenty-one pigs received either 0.2 mg kg(-1) adrenaline (n = 7), 0.2 U kg(-1) vasopressin (n = 7), or 0.8 U kg(-1) vasopressin (n = 7) after 4 min of cardiac arrest and 3 min of CPR. Adrenal gland perfusion was determined using radiolabeled microspheres, noradrenaline plasma concentration was measured by high pressure liquid chromatography.. Before administration of vasopressor drugs during CPR, adrenal gland perfusion, and noradrenaline plasma concentrations were not different between groups. Ninety seconds and 5 min after drug administration, adrenal gland perfusion was significantly higher with both doses of vasopressin when compared with adrenaline, but was not different between the vasopressin groups. Noradrenaline plasma concentrations were 23684 ± 5036 pg ml(-1) with adrenaline, 11455 ± 2450 pg ml(-1) with 0.2 U kg(-1) vasopressin, and 12119 ± 2921 pg ml(-1) with 0.8 U kg(-1) vasopressin at 90 s after administration of vasopressors (p < .05 for both doses of vasopressin vs adrenaline). Five of seven animals in the adrenaline group, five of seven animals in the 0.2 U kg(-1) vasopressin group, and six of seven animals in the 0.8 U kg(-1) vasopressin group were successfully defibrillated.. Vasopressin enhances adrenal gland perfusion, but decreases noradrenaline plasma concentration when compared to adrenaline during CPR. Neither adrenal gland perfusion nor noradrenaline plasma concentration affect survival in this pig model of cardiac arrest.

Topics: Adrenal Glands; Animals; Cardiopulmonary Resuscitation; Chromatography, High Pressure Liquid; Disease Models, Animal; Drug Therapy, Combination; Epinephrine; Heart Arrest; Norepinephrine; Regional Blood Flow; Swine; Vasoconstriction; Vasoconstrictor Agents; Vasopressins

Topics: Anesthetics; Anesthetics, Local; Animals; Bupivacaine; Disease Models, Animal; Dogs; Epinephrine; Fat Emulsions, Intravenous; Heart Arrest; Hypnotics and Sedatives; Rats; Resuscitation; Species Specificity; Swine; Vasoconstrictor Agents; Vasopressins

The San Antonio Vasopressin Symposium reviewed substantial accumulated data concerning vasopressin in haemorrhagic, septic, and cardiac arrest shock conditions and found that there is considerable evidence to support the use of vasopressin in overcoming vasopressin deficiency or insufficiency. The value of vasopressin in the setting of trauma requires further investigation. It was concluded that a large, multicenter controlled trial of vasopressin is needed to assess the therapeutic benefit of vasopressin replacement in the setting of trauma with haemorrhagic shock that is prolonged and profound.

Topics: Brain Injuries; Evidence-Based Medicine; Heart Arrest; Humans; Shock; Texas; Vasopressins

Vasopressin is often used locally to reduce blood loss during surgery. The use of a local infiltration of a low concentration of vasopressin, less than 0.05-0.3 units/mL, has been considered to be safe. The use of low-dose vasopressin is not free of side effects, and it can also sometimes cause lethal complications.. In a healthy woman with multiple uterine myomas, we experienced a case of sudden cardiac arrest immediately after the intramyometrial injection of vasopressin at a total dose of 11 units (0.2 units/mL). The patient was successfully resuscitated.. Local intramyometrial infiltration of low-dose vasopressin may cause lethal cardiopulmonary complications.

Topics: Blood Loss, Surgical; Bradycardia; Dose-Response Relationship, Drug; Female; Heart Arrest; Hemostatics; Humans; Injections, Intramuscular; Laparoscopy; Leiomyomatosis; Vasopressins

To describe the landscape of vasopressin uses reported to the American Heart Association National Registry of cardiopulmonary resuscitation (CPR) and test the hypothesis that vasopressin use will be associated with improved return of a sustained circulation (ROSC) following in-hospital pediatric cardiac arrest.. Multicentered, national registry of in-hospital CPR.. One hundred seventy-six North American Hospitals reporting to registry from October 1999 to November 2004.. Totally, 1293 consecutive pediatric patients with pulseless cardiac arrest meeting criteria for analysis identified from a registry of all patients resuscitated for cardiac arrest. Inclusion criteria were age <18 years, chest compressions and/or defibrillation, in-hospital location, and documented resuscitation record.. None.. Prearrest, event, cardiopulmonary resuscitation, and postresuscitation variables were collected. Primary outcome variable was ROSC >20 minutes. Secondary survival outcomes included 24 hour, discharge and favorable neurologic survival on hospital discharge. Descriptive, univariate, and multivariable analysis to evaluate the association of vasopressin with survival outcomes were performed.. Only 5% of patients received vasopressin in this review. Vasopressin was most often given in a pediatric hospital (57%) and in and intensive care setting (76.6%). Patients who were given vasopressin had longer arrest duration (median 37 minutes) vs. those who did not (24 minutes) (p = 0.004). In multivariate analysis, vasopressin was associated with worse ROSC but no difference in 24 hours or discharge survival.. Vasopressin was given infrequently in in-hospital cardiac arrest. It was most likely to be given in an intensive care setting, and in a pediatric hospital. Multivariate analysis shows an association with vasopressin use and worse ROSC.

Topics: Adolescent; American Heart Association; Cardiopulmonary Resuscitation; Child; Child, Preschool; Education, Medical, Continuing; Female; Heart Arrest; Hospitals, Pediatric; Humans; Infant; Inpatients; Intensive Care Units; Male; Registries; Retrospective Studies; United States; Vasopressins

Lipid emulsion infusion is an emerging antidotal therapy for toxin-induced cardiac arrest. To compare the efficacy of resuscitation from bupivacaine-induced asystole using lipid emulsion infusion vs. vasopressin, alone and with epinephrine.. Prospective, randomized, animal study.. University research laboratory.. Adult, male Sprague-Dawley rats.. Instrumented rats were given an intravenous bolus of 20 mg/kg bupivacaine to induce asystole (zero time). Rats (n = 6 for all groups) were ventilated with 100% oxygen, given chest compressions, and randomized to receive 30% lipid emulsion (L, 5 mL/kg bolus then 1.0 mL/kg/min infusion) and vasopressin 0.4 U/kg bolus alone (V) or combined with epinephrine, 30 microg/kg (V + E); boluses (L, V, or V + E) were repeated at 2.5 and 5 minutes for a rate-pressure product (RPP) less than 20% baseline.. The arterial blood pressure and electrocardiogram were measured continuously for 10 minutes when blood was drawn for arterial blood gas analysis, lactate content, and central venous oxygen saturation (ScvpO2). Hemodynamic parameters of the L group at 10 minutes (30,615 +/- 4782 mm Hg/min; 151 +/- 19.1 mm Hg; 197 +/- 8.6 min; RPP, systolic blood pressure and heart rate, respectively) exceeded those of the V group (5395 +/- 1310 mm Hg/min; 85.8 +/- 12 mm Hg; 61 +/- 10.8 min) and the V + E group (11,183 +/- 1857 mm Hg/min; 75.5 +/- 12.9 min, RPP and heart rate, respectively; systolic blood pressure was not different). Metrics indicated better tissue perfusion in the L group (7.24 +/- 0.02; 83% +/- 3.5%; 2.2 +/- 0.36 mmol/L; pH, ScvpO2, lactate, respectively) than V (7.13 +/- 0.02; 29.9% +/- 4.4%; 7.5 +/- 0.6 mmol/L) and V + E groups (7.07 +/- 0.03; 26.2% +/- 8.9%; 7.7 +/- 1 mmol/L). Wet-to-dry lung ratios in V (8.3 +/- 0.6) and V + E (8.7 +/- 0.2) were greater than that in the L group (6.2 +/- 05) (mean +/- sem; p < 0.05 for all shown results).. Lipid emulsion in this rat model provides superior hemodynamic and metabolic recovery from bupivacaine-induced cardiac arrest than do vasopressors. Systolic pressure was not a useful metric in the vasopressor groups. Vasopressin was associated with adverse outcomes.

Topics: Animals; Bupivacaine; Disease Models, Animal; Epinephrine; Fat Emulsions, Intravenous; Heart Arrest; Male; Rats; Rats, Sprague-Dawley; Resuscitation; Vasoconstrictor Agents; Vasopressins

Topics: Animals; Child; Heart Arrest; Humans; Pediatrics; Vasopressins

This study sought to evaluate the efficacy of lipid emulsion in reversing bupivacaine-induced cardiovascular collapse when added to a resuscitation protocol that included the use of epinephrine and vasopressin.. After induction of general anesthesia and instrumentation, 19 mixed-breed domestic swine had cardiovascular collapse induced by an intravenous bolus of 10 mg/kg bupivacaine. After 5 min of resuscitation including chest compressions, epinephrine (100 microg/kg) and vasopressin (1.5 U/kg), animals were randomized to receive either a bolus of 20% lipid emulsion (4 ml/kg) followed by a continuous infusion (0.5 ml x kg(-1) x min(-1)) or an equal volume of saline. Investigators were blinded to the treatment assignment. The primary endpoint was return of spontaneous circulation (mean arterial pressure of at least 60 mmHg for at least 1 min).. Treatment groups were similar with respect to baseline measurements of weight, sex, and hemodynamic and metabolic variables. The rates of return of spontaneous circulation were similar between groups: (3 of 10) in the lipid group and 4 of 9 in the saline group (P = 0.65). Total serum bupivacaine concentrations were higher in the lipid group at the 10-min timepoint (mean +/- SEM: 23.13 +/- 5.37 ng/ml vs. 15.33 +/- 4.04 ng/ml, P = 0.004). More norepinephrine was required in the lipid group compared to the saline group to maintain a mean arterial pressure above 60 mmHg during the 60-min survival period (mean +/- SEM: 738.6 +/- 94.4 vs.. 487.3 +/- 171.0 microg).. In this swine model, lipid emulsion did not improve rates of return of spontaneous circulation after bupivacaine-induced cardiovascular collapse.

Topics: Animals; Bupivacaine; Disease Models, Animal; Drug Therapy, Combination; Epinephrine; Fat Emulsions, Intravenous; Female; Heart Arrest; Male; Survival Rate; Swine; Vasopressins

Topics: Anesthetics, Local; Bupivacaine; Epinephrine; Fat Emulsions, Intravenous; Heart Arrest; Hemodynamics; Humans; Lactic Acid; Sympathetic Nervous System; Vasoconstrictor Agents; Vasopressins

We report the quantification of a hemodynamic profile sufficient to support consciousness during cardiopulmonary resuscitation. A 62-yr-old man experienced cardiac arrest while being evaluated for heart failure after heart transplantation. During the emergency, hemodynamic data were obtained from bedside monitors and reviewed at regular intervals. His mean arterial blood pressure and heart rate were correlated with consciousness during cardiopulmonary resuscitation. A mean arterial blood pressure of 50 mm Hg with a heart rate of 100 bpm supported consciousness during cardiac arrest. This case helps to validate the recent emphasis on hard, fast, basic life support.

Topics: Blood Pressure; Cardiomyopathy, Dilated; Cardiopulmonary Resuscitation; Consciousness; Epinephrine; Fatal Outcome; Heart Arrest; Heart Failure; Heart Rate; Heart Transplantation; Humans; Male; Middle Aged; Monitoring, Physiologic; Time Factors; Vasoconstrictor Agents; Vasopressins; Withholding Treatment

The advantage of vasopressin over epinephrine in the treatment of cardiac arrest (CA) is still being debated, and it is not clear whether a high dose of vasopressin is beneficial or detrimental during or after cardiopulmonary resuscitation (CPR) in a rat model of CA. In this study, asphyxial CA was induced in 40 male Sprague-Dawley rats. After 10 minutes of asphyxia, CPR was initiated; and the effects of different doses of vasopressin (low dose, 0.4 U/kg; medium dose, 0.8 U/kg; and high dose, 2.4 U/kg; intravenous; n = 10 in each group) and a saline control (isotonic sodium chloride solution, 1 mL, intravenous) were compared. Outcome measures included the rate of restoration of spontaneous circulation (ROSC) and changes of hemodynamic and respiratory variables after ROSC. The rates of ROSC were 1 of 10 in the saline group and 8 of 10 in each of the 3 vasopressin groups. There were no differences in mean aortic pressure or changes of respiratory function after CPR among the vasopressin groups. However, the heart rate was lower in the high-dose vasopressin group than in the low- and medium-dose groups. These findings indicate that different doses of vasopressin result in a similar outcome of CPR, with no additional benefits afforded by a high dose of vasopressin during or after CPR, in a rat model of asphyxial CA. The mechanism and physiologic significance of the relative bradycardia that occurred in the high-dose vasopressin group are currently unknown and require further investigation.

Topics: Animals; Asphyxia; Cardiopulmonary Resuscitation; Disease Models, Animal; Dose-Response Relationship, Drug; Heart Arrest; Male; Rats; Rats, Sprague-Dawley; Vasoconstrictor Agents; Vasopressins

Topics: Anesthetics, Local; Animals; Bupivacaine; Combined Modality Therapy; Dose-Response Relationship, Drug; Epinephrine; Fat Emulsions, Intravenous; Heart Arrest; Hemodilution; Hemodynamics; Rats; Resuscitation; Treatment Outcome; Vasopressins

Patients' outcomes after prolonged cardiac arrest are often grim. The aim of this study was to find the longest period of normovolemic, normothermic, cardiac arrest no-flow after which good neurologic outcome can be achieved with conventional therapies.. Swine (28-37 kg) were subjected to ventricular fibrillation cardiac arrest, after which they were randomized into groups with 13 min (n=6), 15 min (n=6), or 17 min (n=6) of untreated cardiac arrest followed by advanced life support (ALS) for 20 min (epinephrine 0.04 mg/kg every 3 min and vasopressin 0.4 IE/kg every 6 min, no defibrillation attempts), followed by cardiopulmonary bypass (CPB). To mimic an unresuscitable situation after prolonged cardiac arrest, CPB was initiated 20 min after the start of resuscitation, followed by defibrillation attempts. Therapeutic mild hypothermia was applied for 20 h and a final neurologic evaluation (neurologic deficit score, NDS; overall performance category, OPC) was done after 9 days.. In the 13-min group, restoration of spontaneous circulation (ROSC) was achieved in five of six swine, four of which survived to day 9, and all had favorable neurologic outcomes [one swine OPC 1, three swine OPC 2, NDS 15% (IQR 6-21)]. In the 15- and 17-min groups, ROSC was achieved in three of six and two of six swine, respectively, one survived to day 9 with OPC 3 in each group, and NDS values were 45 and 58%, respectively (Kruskal-Wallis test for OPC, p=0.048).. In our model, the limit of normovolemic, normothermic, cardiac arrest no-flow time, followed by ACLS, CPB, and prolonged mild hypothermia, seems to be 13 min.

Topics: Analysis of Variance; Animals; Cardiopulmonary Resuscitation; Electric Countershock; Epinephrine; Heart Arrest; Heart Massage; Hypothermia, Induced; Random Allocation; Swine; Vasopressins

Topics: Cardiopulmonary Resuscitation; Coronary Circulation; Drug Therapy, Combination; Epinephrine; Heart Arrest; Humans; Time Factors; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Topics: Atropine; Cardiopulmonary Resuscitation; Drug Therapy, Combination; Epinephrine; Heart Arrest; Humans; Parasympatholytics; Survival Analysis; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

A 14-year-old boy with catecholamine-induced polymorphic ventricular tachycardia was treated for hypoxic brain injury after a 25-minute ventricular tachycardia arrest. He had been treated by the local paediatric cardiology service with ?-blockers for syncopal events related to episodes of ventricular tachycardia. As standard inotropic support was contraindicated, he was treated for hypoxic brain injury, with targeting of brain tissue oxygen levels (PtO2) with vasopressin. He was extubated after 7 days and discharged home with an automatic implantable cardioverter defibrillator, with no neurological sequelae. PtO2 is a reliable and effective clinical assessment tool that can aid in the management of patients with significant cerebral injury. Vasopressin proved a valuable adjunct in treatment of hypoxic brain injury when inotropic agents were contraindicated.

Topics: Adolescent; Brain; Catecholamines; Heart Arrest; Humans; Hypoxia, Brain; Intracranial Pressure; Male; Oxygen Consumption; Tachycardia, Ventricular; Vasoconstrictor Agents; Vasopressins

Epinephrine remains the drug of choice for cardiopulmonary resuscitation. The aim of the present study is to assess whether the combination of vasopressin and epinephrine, given their different mechanisms of action, provides better results than epinephrine alone in cardiopulmonary resuscitation.. Ventricular fibrillation was induced in 22 Landrace/Large-White piglets, which were left untreated for 8 minutes before attempted resuscitation with precordial compression, mechanical ventilation and electrical defibrillation. Animals were randomized into 2 groups during cardiopulmonary resuscitation: 11 animals who received saline as placebo (20 ml dilution, bolus) + epinephrine (0.02 mg/kg) (Epi group); and 11 animals who received vasopressin (0.4 IU/kg/20 ml dilution, bolus) + epinephrine (0.02 mg/kg) (Vaso-Epi group). Electrical defibrillation was attempted after 10 minutes of ventricular fibrillation.. Ten of 11 animals in the Vaso-Epi group restored spontaneous circulation in comparison to only 4 of 11 in the Epi group (p = 0.02). Aortic diastolic pressure, as well as, coronary perfusion pressure were significantly increased (p < 0.05) during cardiopulmonary resuscitation in the Vaso-Epi group.. The administration of vasopressin in combination with epinephrine during cardiopulmonary resuscitation results in a drastic improvement in the hemodynamic parameters necessary for the return of spontaneous circulation.

Topics: Analysis of Variance; Animals; Cardiopulmonary Resuscitation; Epinephrine; Heart Arrest; Hemodynamics; Random Allocation; Statistics, Nonparametric; Swine; Vasopressins

Topics: Animals; Asphyxia; Cardiopulmonary Resuscitation; Disease Models, Animal; Electrocardiography; Epinephrine; Heart Arrest; Rabbits; Vasopressins

Optimal vasopressor support during resuscitation should theoretically enhance aortic diastolic and coronary perfusion pressure as well as coronary and cerebral blood flow/oxygen delivery without increasing cellular oxygen demand. Intravenous vasopressor support, using 1 mg doses of epinephrine every 5 minutes in adults or vasopressin 40 IU, is recommended by American Heart Association Advanced Cardiac Life Support Guidelines to maximize oxygen delivery to the heart and brain and increase cellular high energy phosphate levels. Vasopressin offers theoretical advantages over epinephrine in that it does not increase myocardial oxygen demand significantly and its receptors are relatively unaffected by acidosis. However, unlike epinephrine, it is not a myocardial stimulant. Despite these differences in physiologic actions, two large randomized clinical trials yielded virtually identical overall survival to hospital discharge when these agents were compared during inhospital or out-of-hospital resuscitation in Canada and Europe, respectively. More recent clinical and experimental evidence suggests that a combination of vasopressin and epinephrine used during resuscitation can improve hemodynamics and perhaps survival. The verdict on a combination vasopressor strategy may soon come from a large (>2,000 patients) prospective clinical trial that is underway in France to clarify the role of combination vasopressin/epinephrine therapy in out-of-hospital resuscitation.

Topics: Animals; Cardiopulmonary Resuscitation; Epinephrine; Heart Arrest; Hemodynamics; Swine; Vasopressins

In a porcine model, we compared the effect of the combination of vasopressin/epinephrine with that of a lipid emulsion on survival after bupivacaine-induced cardiac arrest.. After administration of 5 mg/kg of a 0.5% bupivacaine solution i.v., ventilation was interrupted for 2 +/- 0.5 (mean +/- SD) min until asystole occurred. Cardiopulmonary resuscitation (CPR) was initiated after 1 min of untreated cardiac arrest. After 2 min of CPR, 10 animals received, every 5 min, either vasopressin combined with epinephrine or 4 mL/kg of a 20% lipid emulsion. Three minutes after each drug administration, up to three countershocks (4, 4, and 6 J/kg) were administered; all subsequent shocks with 6 J/kg. Blood for determination of the plasma bupivacaine concentration was drawn throughout the experiment.. In the vasopressor group, all five pigs survived, whereas none of five pigs in the lipid group had restoration of spontaneous circulation (P < 0.01). There was no significant difference between groups in the plasma concentration of total bupivacaine.. In this model of a bupivacaine-induced cardiac arrest, the vasopressor combination of vasopressin and epinephrine compared with lipid emulsion resulted in higher coronary perfusion pressure during CPR and survival rates.

Topics: Anesthetics, Local; Animals; Asphyxia; Bupivacaine; Cardiopulmonary Resuscitation; Coronary Circulation; Disease Models, Animal; Electric Countershock; Epinephrine; Fat Emulsions, Intravenous; Female; Heart Arrest; Hemodynamics; Injections, Intravenous; Male; Swine; Time Factors; Vasoconstrictor Agents; Vasopressins

Vasopressors are recommended for cardiopulmonary resuscitation (CPR) after cardiac arrest. In order to assess possible benefits regarding neurological recovery, vasopressin versus adrenaline and the combination of both was tested against placebo in a cardiac arrest model in rats.. Under anaesthesia with halothane and N2O, cardiac arrest was initiated via transoesophageal electrical fibrillation. After 7 min of global ischaemia, CPR was performed by external chest compression combined with defibrillation. Animals were randomly assigned to three groups receiving adrenaline, vasopressin and a combination of both (n = 15 per group) versus placebo (n = 8). At 1, 3 and 7 days animals were tested according to a neurological deficit score (NDS). After 7 days of reperfusion, coronal brain sections were analysed by Nissl- and TUNEL-staining. Viable as well as TUNEL-positive neurons were counted in the hippocampal CA-1 sector. For statistical analysis, the log rank and the Kruskal-Wallis ANOVA test were used. All data are given as mean+/-S.D.; a p-value <0.05 was considered significant.. Mean arterial blood pressure (MAP) measured in the aorta did not differ between the vasopressor groups, whereas placebo animals had significantly lower levels. Survival to 7 days revealed significant differences between the placebo (n = 0/8) and all vasopressor groups (adrenaline, 10/15; adrenaline/vasopressin, 8/15; vasopressin, 12/15). Histological deficit scoring by quantitative analysis of the Nissl- and TUNEL-staining showed no difference in the amount of viable and apoptotic neurons in the vasopressin group (viable: 33+/-18; apoptotic: 63+/-23) versus the adrenaline group (viable: 21+/-12; apoptotic: 67+/-17) and the adrenaline/vasopressin group (viable: 31+/-26; apoptotic: 61+/-27). Neurological deficit scoring did not show any differences between the vasopressor groups.. Administration of arginine-vasopressin during CPR does not improve behavioural and cerebral histopathological outcome, compared to the use of adrenaline or the combination of both vasopressors, after cardiac arrest in rats.

Topics: Animals; Blood Pressure; Brain; Cardiopulmonary Resuscitation; Drug Therapy, Combination; Epinephrine; Heart Arrest; In Situ Nick-End Labeling; Male; Random Allocation; Rats; Rats, Wistar; Retrograde Degeneration; Vasoconstrictor Agents; Vasopressins

Clinical data considering vasopressin as an equivalent option to epinephrine in cardiopulmonary resuscitation (CPR) are limited. The aim of this prehospital study was to assess whether the use of vasopressin during CPR contributes to higher end-tidal carbon dioxide and mean arterial blood pressure (MAP) levels and thus improves the survival rate and neurological outcome.. Two treatment groups of resuscitated patients in cardiac arrest were compared: in the epinephrine group, patients received 1 mg of epinephrine intravenously every three minutes only; in the vasopressin/epinephrine group, patients received 40 units of arginine vasopressin intravenously only or followed by 1 mg of epinephrine every three minutes during CPR. Values of end-tidal carbon dioxide and MAP were recorded, and data were collected according to the Utstein style.. Five hundred and ninety-eight patients were included with no significant demographic or clinical differences between compared groups. Final end-tidal carbon dioxide values and average values of MAP in patients with restoration of pulse were significantly higher in the vasopressin/epinephrine group (p < 0.01). Initial (odds ratio [OR]: 18.65), average (OR: 2.86), and final (OR: 2.26) end-tidal carbon dioxide values as well as MAP at admission to the hospital (OR: 1.79) were associated with survival at 24 hours. Initial (OR: 1.61), average (OR: 1.47), and final (OR: 2.67) end-tidal carbon dioxide values as well as MAP (OR: 1.39) were associated with improved hospital discharge. In the vasopressin group, significantly more pulse restorations and a better rate of survival at 24 hours were observed (p < 0.05). Subgroup analysis of patients with initial asystole revealed a higher hospital discharge rate when vasopressin was used (p = 0.04). Neurological outcome in discharged patients was better in the vasopressin group (p = 0.04).. End-tidal carbon dioxide and MAP are strong prognostic factors for the outcome of out-of-hospital cardiac arrest. Resuscitated patients treated with vasopressin alone or followed by epinephrine have higher average and final end-tidal carbon dioxide values as well as a higher MAP on admission to the hospital than patients treated with epinephrine only. This combination vasopressor therapy improves restoration of spontaneous circulation, short-term survival, and neurological outcome. In the subgroup of patients with initial asystole, it improves the hospital discharge rate.

Topics: Blood Pressure; Carbon Dioxide; Cardiopulmonary Resuscitation; Epinephrine; Female; Heart Arrest; Humans; Male; Middle Aged; Prognosis; Prospective Studies; Tidal Volume; Treatment Outcome; Vasopressins

Although vasopressin has been reported to be more effective than epinephrine for cardiopulmonary resuscitation in ventricular fibrillation animal models, its efficacy in asphyxia model remains controversy. The purpose of this study was to investigate the effectiveness of vasopressin vs epinephrine on restoration of spontaneous circulation (ROSC) in a rabbit model of asphyxia cardiac arrest. Cardiac arrest was induced by clamping endotracheal tube. After 5 minutes of basic life-support cardiopulmonary resuscitation, animals who had no ROSC were randomly assigned to receive either epinephrine alone (epinephrine group; 200 microg/kg) or vasopressin alone (vasopressin group; 0.8 U/kg). The coronary perfusion pressure (CPP) was calculated as the difference between the minimal diastolic aortic and simultaneously recorded right atrial pressure. Restoration of spontaneous circulation was defined as an unassisted pulse with a systolic arterial pressure of 60 mm Hg or higher for 5 minutes or longer. We induced arrest in 62 rabbits, 15 of whom had ROSC before drug administration and were excluded from analysis. The remaining 47 rabbits were randomized to epinephrine group (n = 24) and vasopressin group (n = 23). Before and after drug administration, CPP in epinephrine group increased significantly (from -4 +/- 4 to 36 +/- 9 mm Hg at peak value, P = .000), whereas CPP in vasopressin group increased only slightly (from 9 +/- 5 to 18 +/- 6 mm Hg at peak value, P = .20). After drug administration, 13 of 24 epinephrine rabbit had ROSC, and only 2 of 23 vasopressin rabbit had ROSC (P < .01). Consequently, we conclude that epinephrine, but not vasopressin, increases survival rates in this adult rabbit asphyxia model.

Topics: Analysis of Variance; Animals; Asphyxia; Cardiopulmonary Resuscitation; Disease Models, Animal; Electrocardiography; Epinephrine; Heart Arrest; Rabbits; Vasopressins

Synergistic effects of adrenaline (epinephrine) and vasopressin may be beneficial during cardiopulmonary resuscitation. However, it is unknown whether either adrenaline alone or an alternating administration of adrenaline and vasopressin is better for restoring vital organ perfusion following basic life support (BLS) according to the revised algorithm with a compression-to-ventilation (c/v) ratio of 30:2.. After 4min of ventricular fibrillation, and 6min of BLS with a c/v ratio of 30:2, 16 pigs were randomised to receive either 45microg/kg adrenaline, or alternating 45microg/kg adrenaline and 0.4U/kg vasopressin, respectively.. Coronary perfusion pressure (mean+/-S.D.) 20 and 25min after cardiac arrest was 7+/-4 and 5+/-3mm Hg after adrenaline, and 25+/-2 and 14+/-3mm Hg after adrenaline/vasopressin (p<0.001 and <0.01 versus adrenaline), respectively. Cerebral perfusion pressure was 23+/-7 and 19+/-9mm Hg after adrenaline, and 40+/-10 and 33+/-7mm Hg after adrenaline/vasopressin (p<0.001 and <0.01 versus adrenaline), and cerebral blood flow was 30+/-10 and 27+/-11% of baseline after adrenaline, and 65+/-40 and 50+/-31% of baseline after adrenaline/vasopressin (p<0.05 versus adrenaline), respectively. Return of spontaneous circulation (ROSC) did not differ significantly between the adrenaline group (0/8) and the adrenaline/vasopressin group (3/8).. Adrenaline/vasopressin resulted in higher coronary and cerebral perfusion pressures, and cerebral blood flow, while ROSC was comparable.

Topics: Animals; Cardiopulmonary Resuscitation; Cerebrovascular Circulation; Coronary Circulation; Disease Models, Animal; Drug Therapy, Combination; Epinephrine; Female; Heart Arrest; Male; Practice Guidelines as Topic; Random Allocation; Swine; Treatment Outcome; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

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.. 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 vasopressin (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.. 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.. 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.

Topics: Adult; Aged; Ambulatory Care; Cardiopulmonary Resuscitation; Cohort Studies; Female; Heart Arrest; Humans; Male; Middle Aged; Prospective Studies; Survival Rate; Tachycardia, Ventricular; Treatment Outcome; Vasopressins; Ventricular Fibrillation

Direct measurement of brain tissue oxygenation (PbtO2) is established during spontaneous circulation, but values of PbtO2 during and after cardiopulmonary resuscitation (CPR) are unknown. The purpose of this study was to investigate: (1) the time-course of PbtO2 in an established model of CPR, and (2) the changes of cerebral venous lactate and S-100B.. In 12 pigs (12-16 weeks, 35-45 kg), ventricular fibrillation (VF) was induced electrically during general anaesthesia. After 4 min of untreated VF, all animals were subjected to CPR (chest compression rate 100/min, FiO2 1.0) with vasopressor therapy after 7, 12, and 17 min (vasopressin 0.4, 0.4, and 0.8 U/kg, respectively). Defibrillation was performed after 22 min of cardiac arrest. After return of spontaneous circulation (ROSC), the pigs were observed for 1h.. After initiation of VF, PbtO2 decreased compared to baseline (mean +/- SEM; 22 +/- 6 versus 2 +/- 1 mmHg after 4 min of VF; P < 0.05). During CPR, PbtO2 increased, and reached maximum values 8 min after start of CPR (25 +/- 7 mmHg; P < 0.05 versus no-flow). No further changes were seen until ROSC. Lactate, and S-100B increased during CPR compared to baseline (16 +/- 2 versus 85 +/- 8 mg/dl, and 0.46 +/- 0.05 versus 2.12 +/- 0.40 microg/l after 13 min of CPR, respectively; P < 0.001); lactate remained elevated, while S-100B returned to baseline after ROSC.. Though PbtO2 returned to pre-arrest values during CPR, PbtO2 and cerebral lactate were lower than during post-arrest reperfusion with 100% oxygen, which reflected the cerebral low-flow state during CPR. The transient increase of S-100B may indicate a disturbance of the blood-brain-barrier.

Topics: Animals; Brain; Brain Chemistry; Cardiopulmonary Resuscitation; Cerebrovascular Circulation; Disease Models, Animal; Electric Countershock; Female; Heart Arrest; Lactates; Male; Oxygen; Swine; Vasopressins; Ventricular Fibrillation

Survival after prolonged cardiopulmonary resuscitation (CPR) is often associated with neurological and other sequelae. We describe a patient who survived prolonged cardiac arrest due to ventricular fibrillation neurologically intact but suffered colon ischaemia and necrosis in the post-resuscitation period. Subtotal colectomy was performed. We wonder whether this complication was related to the use of vasopressin.

Topics: Adrenergic Agonists; Adult; Amiodarone; Anti-Arrhythmia Agents; Cardiopulmonary Resuscitation; Colectomy; Colon; Electric Countershock; Epinephrine; Female; Heart Arrest; Humans; Ischemia; Necrosis; Time Factors; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

Topics: Animals; Blood Pressure; Coronary Circulation; Disease Models, Animal; Drug Therapy, Combination; Electric Countershock; Epinephrine; Heart Arrest; Pulse; Swine; Vasoconstrictor Agents; Vasopressins

Vasopressin has been documented to effectively reduce blood loss in gynecologic practice. However, local infiltration of vasopressin may cause lethal cardiopulmonary complications in spite of rarity of reported cases. Severe bradycardia and cardiac arrest were encountered after intramyometrial injection of vasopressin in our two healthy patients undergoing open uterine myomectomy. We herewith discuss the associated complications and the anesthetic considerations.

Topics: Adult; Baroreflex; Bradycardia; Female; Heart Arrest; Hemostatics; Humans; Injections; Myometrium; Pulmonary Edema; Vasopressins

Resuscitation of patients in hemorrhagic shock remains one of the most challenging aspects of trauma care. We showed in experimental studies that vasopressin, but not fluid resuscitation, enabled short-term and long-term survival in a porcine model of uncontrolled hemorrhagic shock after penetrating liver trauma. In this case report, we present two cases with temporarily successful cardiopulmonary resuscitation (CPR) using vasopressin and catecholamines in uncontrolled hemorrhagic shock with subsequent cardiac arrest that was refractory to catecholamines and fluid replacement. In a third patient, an infusion of vasopressin was started before cardiac arrest occurred; in this case, we were able to stabilize blood pressure thus allowing further therapy. The patient underwent multiple surgical procedures, developed multi-organ failure, but was finally discharged from the critical care unit without neurological damage.

Topics: Abdominal Injuries; Accidental Falls; Accidents, Traffic; Adult; Aged; Cardiopulmonary Resuscitation; Female; Heart Arrest; Humans; Male; Multiple Organ Failure; Shock, Hemorrhagic; Vasoconstrictor Agents; Vasopressins; Wounds and Injuries; Wounds, Stab

That endogenous vasopressin levels in successfully resuscitated human patients were significantly higher than in patients who died pointed to the possible benefit of administering vasopressin during cardiopulmonary resuscitation (CPR). Several CPR studies in pigs showed that vasopressin improved blood flow to vital organs, cerebral oxygen delivery, resuscitability and neurological outcome when compared with epinephrine. In a small clinical study, vasopressin significantly improved short-term survival when compared with epinephrine indicating its potential as an alternative pressor to epinephrine during CPR in human beings. As there was little clinical data available at that time, its recommended use was limited to adult human beings with shock-refractory ventricular fibrillation. In this report, we present the case of a dog in which the successful management of intraoperative asystolic cardiac arrest involved vasopressin. Unexpected cardiac arrest occurred during anaesthesia for the surgical removal of multiple mammary adenocarcinomata in a 11-year-old Yorkshire terrier. Despite an ASA physical status assignation of III, the dog was successfully resuscitated with external chest compressions, intermittent positive pressure ventilation and vasopressin (2 doses of 0.8 IU kg(-1)) and was discharged 3 days later without signs of neurological injury. We believe vasopressin contributed to restoring spontaneous circulation. It may prove increasingly useful in perioperative resuscitation in dogs.

Topics: Anesthesia; Animals; Cardiopulmonary Resuscitation; Diagnosis, Differential; Dog Diseases; Dogs; Female; Heart Arrest; Hemostatics; Intraoperative Complications; Mammary Neoplasms, Animal; Vasopressins

To report a cardiopulmonary resuscitation attempt in a 20-month-old child employing a combination of vasopressin and epinephrine.. Case report.. Out-of-hospital cardiopulmonary resuscitation.. A 20-month-old child found in cardiac arrest after submersion.. Dispatcher-assisted basic life support was initiated immediately after pulling the child out of the water. The emergency medical service crew arrived approximately 6 mins later and found a hypothermic, cyanotic child in cardiocirculatory arrest. The first electrocardiogram showed sinus bradycardia. After intubation and administration of epinephrine and atropine with no effect, an intravenous bolus of 0.2 mg of epinephrine and 10 IU of vasopressin resulted in restoration of spontaneous circulation. The boy was flown to a hospital and was discharged 23 days later to a rehabilitation facility. He returned home 6 months after the accident, where further rehabilitation efforts are pending.. Bystander cardiopulmonary resuscitation, early and aggressive advanced life support, rewarming, and the combination of intravenous epinephrine and vasopressin were associated with sustained return of spontaneous circulation following hypothermic submersion-associated cardiac arrest.

Topics: Cardiopulmonary Resuscitation; Drug Therapy, Combination; Epinephrine; Heart Arrest; Humans; Hypothermia; Infant; Male; Near Drowning; Vasoconstrictor Agents; Vasopressins

Topics: Drug Costs; Epinephrine; Heart Arrest; Humans; United States; Vasoconstrictor Agents; Vasopressins

Although published algorithms and guidelines list epinephrine and vasopressin as either/or choices for treatment of ventricular fibrillation and/or pulseless ventricular tachycardia, little is known about how critical care providers respond to this recommendation.. To assess the use of vasopressin as a first-line drug of choice for ventricular fibrillation and/or pulseless ventricular tachycardia and describe factors that may influence decision making for using vasopressin.. A convenience sample from 4 academic medical centers in the United States was recruited to complete a 20-item survey on demographic factors such as year of last Advanced Cardiac Life Support (ACLS) provider course, specialty certification, predominant practice responsibility, and beliefs related to the use of vasopressin for cardiac arrest. Descriptive statistics, Pearson correlation analysis, and logistic regression were used to analyze the data.. A total of 214 critical care providers (80% registered nurses) completed the survey. Year of last ACLS course (r=-0.188, P=.006) was a significant demographic factor, and behavioral beliefs (attitude about using vasopressin) had the strongest relationship (r=0.687, P<.001) and were the best predictor for intentions to use or recommend the use of vasopressin (beta=0.589, P<.001).. Despite the recommendation for vasopressin as an agent equivalent to epinephrine for treatment of ventricular fibrillation and/or pulseless ventricular tachycardia, 63% of respondents used epinephrine as a first-line drug of choice. More research is needed to address the classification system for interpreting the quality of evidence that may influence practice.

Topics: Academic Medical Centers; Adult; Attitude of Health Personnel; Data Collection; Emergency Medical Services; Female; Heart Arrest; Humans; Male; Middle Aged; United States; Vasoconstrictor Agents; Vasopressins

Synergistic effects of epinephrine and vasopressin may be of benefit during cardiopulmonary resuscitation. However, cerebral perfusion was decreased when epinephrine was combined with vasopressin compared with vasopressin alone. Although a combined infusion of norepinephrine and vasopressin improves hemodynamic variables compared with norepinephrine alone during sepsis, it is unknown whether norepinephrine in addition to vasopressin and epinephrine changes vital organ perfusion during cardiopulmonary resuscitation.. Prospective, randomized animal study.. : University hospital research laboratory.. Twenty-one domestic pigs.. After 4 mins of ventricular fibrillation and 3 mins of basic life support, the pigs were randomly assigned to receive either 200 microg/kg epinephrine, 0.4 units/kg vasopressin alone, or 45 microg/kg norepinephrine plus 45 microg/kg epinephrine plus 0.4 units/kg vasopressin before defibrillation.. Organ perfusion was determined by radiolabeled microspheres. Myocardial blood flow (mean +/- sem) before and 90 secs and 5 mins after drug administration was 8 +/- 2, 25 +/- 6, and 7 +/- 1 mL/min/100 g after high-dose epinephrine, 12 +/- 1, 75 +/- 7, and 60 +/- 10 mL/min/100 g after vasopressin, and 9 +/- 2, 95 +/- 26, and 46 +/- 15 mL/min/100 g after vasopressin/epinephrine/norepinephrine, respectively (p < .05 at 90 secs and 5 mins vasopressin vs. epinephrine and vasopressin/epinephrine/norepinephrine vs. epinephrine). At the same time points, cerebral blood flow was 8 +/- 2, 23 +/- 3, and 17 +/- 3 mL/min/100 g after epinephrine, 11 +/- 3, 55 +/- 7, and 52 +/- 7 mL/min/100 g after vasopressin, and 11 +/- 4, 67 +/- 13, and 53 +/- 12 mL/min/100 g after vasopressin/epinephrine/norepinephrine, respectively (p < .05 at 90 secs and 5 mins vasopressin vs. epinephrine and vasopressin/epinephrine/norepinephrine vs. epinephrine). Two of seven animals in the epinephrine group, four of seven animals in the vasopressin/epinephrine/norepinephrine group, and seven of seven animals in the vasopressin group could be successfully resuscitated (p < .05 vasopressin vs. epinephrine).. Vasopressin with or without epinephrine and norepinephrine resulted in higher myocardial and cerebral perfusion than epinephrine alone, but there was no benefit in adding norepinephrine to vasopressin and epinephrine with regard to cardiac and cerebral blood flow during cardiopulmonary resuscitation.

Topics: Animals; Blood Pressure; Cardiopulmonary Resuscitation; Cerebrovascular Circulation; Drug Synergism; Epinephrine; Female; Heart Arrest; Male; Norepinephrine; Swine; Sympathomimetics; Vasopressins

Topics: Cardiopulmonary Resuscitation; Drug Therapy, Combination; Epinephrine; Heart Arrest; Humans; Practice Guidelines as Topic; Sympathomimetics; Vasoconstrictor Agents; Vasopressins

Topics: Heart Arrest; Humans; Vasoconstrictor Agents; Vasopressins

Topics: Cardiotonic Agents; Heart Arrest; Humans; Vasopressins

In a porcine model, we compared the efficacy of epinephrine, vasopressin, or the combination of epinephrine and vasopressin with that of saline placebo on the survival rate after bupivacaine-induced cardiac arrest. After the administration of 5 mg/kg of a 0.5% bupivacaine solution i.v., ventilation was interrupted for 3 +/- 1 min (mean +/- SD) until asystole occurred. Cardiopulmonary resuscitation (CPR) was initiated after 1 min of cardiac arrest. After 2 min of CPR, 28 animals received, every 5 min, epinephrine; vasopressin; epinephrine combined with vasopressin; or placebo i.v.. Three minutes after each drug administration, up to 3 countershocks (3, 4, and 6 J/kg) were administered; all subsequent shocks were 6 J/kg. Blood was drawn throughout the experiment for the determination of plasma bupivacaine concentration. In the vasopressin/epinephrine combination group, all pigs survived (P < 0.01 versus placebo); in the vasopressin group 5 of 7, in the epinephrine group 4 of 7, and in the placebo group none of 7 swine survived. The plasma concentration of total bupivacaine showed no significant difference among groups. In this model of bupivacaine-induced cardiac arrest, CPR with a combination of vasopressin and epinephrine resulted in significantly better survival rates than in the placebo group.. Although cardiovascular collapse occurs mostly immediately after rapid injection of a local anesthetic in the presence of anesthesiologists, resuscitation may be difficult, and the outcome is usually poor. In this model of bupivacaine-induced cardiac arrest, cardiopulmonary resuscitation with a combination of vasopressin and epinephrine resulted in significantly better survival rates than in the placebo group.

Topics: Anesthetics, Local; Animals; Bupivacaine; Cardiac Output; Drug Combinations; Epilepsy, Tonic-Clonic; Epinephrine; Female; Heart Arrest; Hemodynamics; Injections, Intravenous; Male; Survival; Swine; Vascular Resistance; Vasoconstrictor Agents; Vasopressins

Topics: Cardiopulmonary Resuscitation; Heart Arrest; Humans; Survival Rate; Vasoconstrictor Agents; Vasopressins

Topics: Cardiopulmonary Resuscitation; Epinephrine; Heart Arrest; Humans; Sympathomimetics; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

Topics: Brain Diseases; Cardiopulmonary Resuscitation; Heart Arrest; Humans; Survival Rate; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Topics: Brain Diseases; Cardiopulmonary Resuscitation; Drug Therapy, Combination; Epinephrine; Heart Arrest; Humans; Sympathomimetics; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Topics: Cardiopulmonary Resuscitation; Epinephrine; Heart Arrest; Humans; Vasoconstrictor Agents; Vasopressins

Topics: Cardiopulmonary Resuscitation; Epinephrine; Evidence-Based Medicine; Heart Arrest; Humans; Vasoconstrictor Agents; Vasopressins

NEW RECOMMENDATIONS: for cardio-pulmonary resuscitation Methods such as mouth to mouth or the search for a pulse, until now the fundamental preliminaries, have now become second line. Everything must be organised to allow for defibrillation as rapidly as possible. NEW MODALITIES FOR CARDIAC MASSAGE: The frequency of compressions recommended is currently 100 per minute in the adult with a rhythm of compression-ventilation reaching 15/2 before intubation. Concerning the haemodynamic agents for cardiac arrest, the efficacy of high doses of adrenalin is not greater than with conventional doses. Vasopressin is not superior to intravenous adrenalin regarding survival at 24 hrs exepet in case of asystoly. Dopamine at a "renal" dose is no longer used. ANTIARRYTHMICS: Amiodarone is part of the decisional tree in the case of ventricular fibrillation or ventricular tachycardia without a pulse. Semi-automatic defibrillator accessibility should be generalized. INFUSED SOLUTIONS: Sodium bicarbonate does not improve the survival except in particular cases. Physiological serum should be preferred to glucosed serum during reanimation.

Topics: Adult; Aftercare; Algorithms; Amiodarone; Cardiopulmonary Resuscitation; Cardiovascular Agents; Decision Trees; Electric Countershock; Electrocardiography; Epinephrine; Fluid Therapy; France; Heart Arrest; Hemodynamics; Humans; Physical Examination; Practice Guidelines as Topic; Respiration, Artificial; Sodium Bicarbonate; Survival Analysis; Treatment Outcome; United States; Vasopressins

Topics: Cardiopulmonary Resuscitation; Emergency Medical Services; Epinephrine; Heart Arrest; Humans; Organizational Innovation; Respiration, Artificial; United States; Vasopressins

To compare the effect on postresuscitation left ventricular function of vasopressin vs. epinephrine used during cardiopulmonary resuscitation in a swine model of prolonged prehospital ventricular fibrillation.. Prospective, randomized experimental study.. University large animal resuscitation research laboratory.. Forty-eight swine (29 +/- 1 kg).. Resuscitation after 12.5 mins of untreated ventricular fibrillation, randomizing animals during cardiopulmonary resuscitation to treatment with epinephrine, vasopressin, or vasopressin followed by a vasopressin antagonist administered in the postresuscitation period.. Serial measurements of left ventricular systolic and diastolic function (prearrest, postresuscitation at 30 mins and 6 hrs) and 24-hr survival. Animals receiving vasopressin had more postresuscitation left ventricular dysfunction than those receiving epinephrine (p < .05). The vasopressin antagonist produced vasodilation and improved early postresuscitation left ventricular systolic and diastolic function but did not have a lasting effect on such postresuscitation ventricular function and decreased 24-hr survival compared with the use of vasopressin alone (3/16 vs. 10/16 survivors; p < .05).. Vasopressin use during cardiopulmonary resuscitation results in worse postresuscitation left ventricular function early but did not compromise 24-hr outcome. Reversal of vasopressin's effect with a specific V-1 antagonist in the postresuscitation period did not improve survival.

Topics: Animals; Cardiopulmonary Resuscitation; Emergency Medical Services; Epinephrine; Female; Heart Arrest; Male; Practice Guidelines as Topic; Swine; Vasoconstrictor Agents; Vasopressins; Ventricular Function, Left

Recent animal data have challenged the common clinical practice to avoid vasopressor drugs during hypothermic cardiopulmonary resuscitation (CPR) when core temperature is below 30 degrees C. In this report, we describe the case of a 19-year-old-female patient with prolonged, hypothermic, out-of-hospital cardiopulmonary arrest after near drowning (core temperature, 27 degrees C) in whom cardiocirculatory arrest persisted despite 2 mg of intravenous epinephrine; but, immediate return of spontaneous circulation occurred after a single dose (40 IU) of intravenous vasopressin. The patient was subsequently admitted to a hospital with stable haemodynamics, and was successfully rewarmed with convective rewarming, but died of multiorgan failure 15 h later. To the best of our knowledge, this is the first report about the use of vasopressin during hypothermic CPR in humans. This case report adds to the growing evidence that vasopressors may be useful to restore spontaneous circulation in hypothermic cardiac arrest patients prior to rewarming, thus avoiding prolonged mechanical CPR efforts, or usage of extracorporeal circulation. It may also support previous experience that the combination of both epinephrine and vasopressin may be necessary to achieve the vasopressor response needed for restoration of spontaneous circulation, especially after asphyxial cardiac arrest or during prolonged CPR efforts.

Topics: Adult; Blood Circulation; Cardiopulmonary Resuscitation; Epinephrine; Fatal Outcome; Female; Heart Arrest; Hemodynamics; Humans; Hypothermia; Multiple Organ Failure; Near Drowning; Rewarming; Vasoconstrictor Agents; Vasopressins

We sought to determine the effects of a combination of vasopressin and epinephrine on neurologic recovery in comparison with epinephrine alone and saline placebo alone in an established porcine model of prolonged cardiopulmonary resuscitation (CPR). After 4 min of cardiac arrest, followed by 3 min of basic life support CPR, 17 animals were randomly assigned to receive, every 5 min, either a combination of vasopressin and epinephrine (vasopressin [IU/kg]/epinephrine [ micro g/kg]: 0.4/45, 0.4/45, and 0.8/45; n = 6), epinephrine alone (45, 45, and 200 micro g/kg; n = 6), or saline placebo alone (n = 5). After 22 min of cardiac arrest, including 18 min of CPR, defibrillation was attempted to achieve the return of spontaneous circulation. Aortic diastolic pressure was significantly (P < 0.01) increased 90 s after each of 3 vasopressin/epinephrine injections versus epinephrine alone versus saline placebo alone (mean +/- SEM: 69 +/- 3 mm Hg versus 45 +/- 3 mm Hg versus 29 +/- 2 mm Hg, 63 +/- 4 mm Hg versus 27 +/- 3 mm Hg versus 23 +/- 1 mm Hg, and 52 +/- 4 mm Hg versus 21 +/- 3 mm Hg versus 16 +/- 3 mm Hg, respectively). Spontaneous circulation was restored in six of six vasopressin/epinephrine pigs, whereas six of six epinephrine and five of five saline placebo pigs died (P < 0.01). Neurologic evaluation 24 h after successful resuscitation revealed only an unsteady gait and was normal 5 days after the experiment in all vasopressin/epinephrine-treated animals. In conclusion, in this porcine model of prolonged CPR, repeated vasopressin/epinephrine administration, but not epinephrine or saline placebo alone, ensured long-term survival with full neurologic recovery.. We present a study to evaluate the effects of a combination of vasopressin and epinephrine during prolonged cardiopulmonary resuscitation on neurological outcome in pigs. We found that all pigs treated with a combination of vasopressin and epinephrine could be resuscitated and had full neurologic recovery observed over an entire period of 5 days.

Topics: Animals; Blood Gas Analysis; Blood Pressure; Body Weight; Cardiopulmonary Resuscitation; Drug Combinations; Electric Countershock; Electrocardiography; Epinephrine; Heart Arrest; Hemodynamics; Lactic Acid; Nervous System Diseases; Survival; Swine; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

Topics: Cardiovascular Agents; Drug Compounding; Drug Evaluation; Drug Incompatibility; Drug Therapy, Combination; Heart Arrest; Humans; Vasopressins

Aim of this experimental animal study was to investigate the influence of vasopressin and amiodarone on cardiopulmonary resuscitation (CPR) outcome in a pig model of hypothermic cardiac arrest.. After surface cooling to a core temperature of 26 degrees C, ventricular fibrillation was induced in 14 12-16-week-old domestic pigs. After 15 min of untreated cardiac arrest, a manual closed chest CPR was started and pigs were randomly assigned to two treatment groups: Group 1 pigs (n = 7) received vasopressin 0.4 U kg-1 as initial drug therapy, followed by a combination vasopressin (0.4 U kg-1) and amiodarone (4 mg kg-1) as subsequent drug therapy. Subsequent drug therapy was administered in animals without permanent restoration of spontaneous circulation after a first series of electrical countershocks 10 min after drug administration. Group 2 pigs (n = 7) received saline placebo as initial drug therapy and saline placebo and amiodarone (4 mg kg-1) as subsequent drug therapy.. Vasopressin significantly increased coronary perfusion pressure and defibrillation success (successful defibrillation in five of seven Group 1 vs. none of seven Group 2 pigs, P = 0.02). Due to refibrillation within 30-150 s, the 60-min survival rate was not improved by vasopressin. Subsequent drug therapy with amiodarone had no further effect on defibrillation success or the refibrillation rate.. Data from this experimental animal model suggest that vasopressin and amiodarone may not be beneficial for treatment of ventricular fibrillation associated with severe hypothermia when concomitant measures at core rewarming are not applied.

Topics: Amiodarone; Animals; Blood Pressure; Cardiopulmonary Resuscitation; Coronary Vessels; Disease Models, Animal; Heart Arrest; Hypothermia; Survival Rate; Swine; Vasopressins

Both alpha1- and beta-adrenergic agonists increase the severity of global myocardial ischemic injury. We hypothesized that combined beta- and alpha1-adrenergic blockade would improve initial resuscitation and postresuscitation myocardial and neurological functions. We further hypothesized that the resulting alpha2-actions of relatively brief duration would favor improved functions compared with the more prolonged effect of nonadrenergic vasopressin.. Three groups of 5 male domestic pigs weighing 37+/-3 kg were investigated. Ventricular fibrillation was untreated for 7 minutes before the start of precordial compression, mechanical ventilation, and attempted defibrillation. Animals were randomized to receive central venous injections of equipressor doses of (1) epinephrine, (2) epinephrine in which both alpha1- and beta-adrenergic effects were blocked by previous administration of prazosin and propranolol, and (3) vasopressin during CPR. All but 1 animal were successfully resuscitated. After injection of epinephrine, significantly better cardiac output and fractional area change, together with lesser increases in troponin I, were observed after alpha1- and beta-adrenergic blockade. Postresuscitation neurological function was also improved after alpha1- and beta-block in comparison with unblocked epinephrine and after vasopressin.. Equipressor doses of epinephrine, epinephrine after alpha1- and beta-adrenergic blockade, and vasopressin were equally effective in restoring spontaneous circulation after prolonged ventricular fibrillation. However, combined alpha1- and beta-adrenergic blockade, which represented a predominantly selective alpha2-vasopressor effect, resulted in improved postresuscitation cardiac and neurological recovery.

Topics: Adrenergic Agonists; Adrenergic alpha-Antagonists; Adrenergic beta-Antagonists; Animals; Blood Pressure; Cardiopulmonary Resuscitation; Disease Models, Animal; Drug Therapy, Combination; Electric Countershock; Epinephrine; Heart Arrest; Heart Massage; Male; Prazosin; Propranolol; Recovery of Function; Respiration, Artificial; Swine; Treatment Outcome; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

Microdialysis is an established tool to analyse tissue biochemistry, but the value of this technique to monitor cardiopulmonary resuscitation (CPR) effects on cerebral metabolism is unknown. The purpose of this study was to assess the effects of active-compression-decompression (ACD) CPR in combination with an inspiratory threshold valve (ITV) (=experimental CPR) vs. standard CPR on cerebral metabolism measured with microdialysis.. Fourteen domestic pigs were surfaced-cooled to a body core temperature of 26 degrees C and ventricular fibrillation was induced, followed by 10 min of untreated cardiac arrest; and subsequently, standard (n=7) CPR vs. experimental (n=7) CPR. After 8 min of CPR, all animals received 0.4 U/kg vasopressin IV, and CPR was maintained for an additional 10 min in each group; defibrillation was attempted after a total of 28 min of cardiac arrest, including 18 min of CPR.. In the standard CPR group, microdialysis measurements showed a 13-fold increase of the lactate-pyruvate ratio from 7.2+/-1.3 to 95.5+/-15.4 until the end of CPR (P<0.01), followed by a further increase up to 138+/-32 during the postresuscitation period. The experimental group developed a sixfold increase of the lactate-pyruvate ratio from 7.1+/-2.0 to 51.1+/-8.7 (P<0.05), and a continuous decrease after vasopressin. In the standard resuscitated group, but not during experimental CPR, a significant increase of cerebral glucose levels from 0.6+/-0.1 to 2.6+/-0.5 mM was measured (P<0.01).. Using the technique of microdialysis we were able to measure changes of brain biochemistry during and after the very special situation of hypothermic cardiopulmonary arrest. Experimental CPR improved the lactate-pyruvate ratio, and glucose metabolism.

Topics: Analysis of Variance; Animals; Brain; Brain Ischemia; Cardiopulmonary Resuscitation; Cerebrovascular Circulation; Disease Models, Animal; Female; Heart Arrest; Male; Microdialysis; Probability; Random Allocation; Risk Assessment; Statistics, Nonparametric; Survival Rate; Sus scrofa; Vasopressins

There is increasing evidence that the combination of epinephrine (adrenaline) with vasopressin may be superior to either epinephrine or vasopressin alone for treatment of cardiac arrest. However, the optimal combination, and dosage of cardiovascular drugs to minimize side effects, and to improve outcome has yet to be found. We therefore evaluated whether the combination of vasopressin plus epinephrine plus nitroglycerin (EVN), would improve vital organ blood flow during cardiopulmonary resuscitation (CPR) when compared with epinephrine (EPI) alone. After 4 min of ventricular fibrillation (VF) and 4 min of standard CPR, pigs were randomized to the combination of epinephrine (45 microg/kg) plus vasopressin (0.4 U/kg) plus nitroglycerin (7.5 microg/kg; n=12), or epinephrine (40 microg/kg; n=12) alone. Cerebral and myocardial blood flow was measured with radiolabeled microspheres. Defibrillation was attempted after 19 min of VF including 15 min of CPR. Mean+/-SEM coronary perfusion pressures were significantly (P < 0.01) higher 5 min after EVN vs. EPI alone (34+/-3 vs. 24+/-3 mmHg, respectively). At the same time, mean+/-SEM left ventricular, and global cerebral blood flow was also significantly (P < 0.05) higher after EVN vs. EPI alone (0.78+/-0.11 vs. 0.48+/-0.08 ml/min/g; and 0.37+/-0.05 vs. 0.22+/-0.0 3 ml/min/g, respectively). Spontaneous circulation was restored in 11 of 12 animals in the EVN group vs. 6 of 12 swine after EPI alone (P = N.S.). In conclusion, the combination of EVN significantly improved vital organ blood flow during CPR compared with EPI alone. Addition of nitroglycerin to the combination of low dose epinephrine with vasopressin during cardiac arrest may be beneficial.

Topics: Animals; Cardiopulmonary Resuscitation; Cerebrovascular Circulation; Coronary Circulation; Drug Therapy, Combination; Epinephrine; Heart Arrest; Nitroglycerin; Swine; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

We estimated the predictive power with respect to defibrillation outcome of ventricular fibrillation (VF) mean frequency (FREQ), mean peak-to-trough amplitude (AMPL), and their combination. We examined VF electrocardiogram signals of 64 pigs from 4 different cardiac arrest models with different durations of untreated VF, different durations of cardiopulmonary resuscitation, and use of different drugs (epinephrine, vasopressin, N-nitro-L-arginine methyl ester, or saline placebo). The frequency domain was restricted to the range from 4.33 to 30 Hz. In the 10-s epoch between 20 and 10 s before the first defibrillation shock, FREQ and AMPL were estimated. We introduced the survival index (SI; 0.68 Hz(-1). FREQ + 12.69 mV(-1). AMPL) by use of multiple logistic regression. Kruskal-Wallis nonparametric one-way analysis was used to analyze the different porcine models for significant difference. The variables FREQ, AMPL, and SI were compared with defibrillation outcome by means of univariate logistic regression and receiver operating characteristic curves. SI increased predictive power compared with AMPL or FREQ alone, resulting in 89% sensitivity and 86% specificity. The probabilities of predicting defibrillation outcome for FREQ, AMPL, and SI were 0.85, 0.89 and 0.90, respectively. FREQ, AMPL, and SI values were not sensitive in regard to the four different cardiac arrest models but were significantly different for vasopressin and epinephrine animals.. We present a retrospective data analysis to evaluate the predictive power of different ventricular fibrillation electrocardiogram variables in pigs with respect to defibrillation outcome. We showed that our combination of variables leads to an improved forecast, which may help to reduce harmful unsuccessful defibrillation attempts.

Topics: Algorithms; Animals; Cardiopulmonary Resuscitation; Electric Countershock; Enzyme Inhibitors; Epinephrine; Female; Heart Arrest; Male; NG-Nitroarginine Methyl Ester; Predictive Value of Tests; Regression Analysis; Survival Analysis; Swine; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Children who suffer cardiac arrest have a poor prognosis. Based on laboratory animal studies and clinical data in adults, vasopressin is an exciting new vasopressor treatment modality during cardiopulmonary resuscitation (CPR). In particular, vasopressin has resulted in short term resuscitation benefits as a "rescue" pressor agent in the setting of prolonged out-of-hospital CPR for ventricular fibrillation in adults. This retrospective series presents the first evidence for resuscitation benefit of bolus vasopressin therapy in the specific setting of pediatric cardiac arrest. All episodes of CPR initiated in a 120-bed tertiary care children's hospital over a three-year period (1997-2000) were reviewed. Four children in the pediatric ICU received vasopressin boluses as rescue therapy during six cardiac arrest events, following failure of conventional CPR, advanced life support, and epinephrine vasopressor therapy. Return of spontaneous circulation for greater than 60 min occurred in three of four patients (75%) and in four of six CPR events (66%) following vasopressin administration. Two of four vasopressin recipients survived >24 h; one survived to hospital discharge and one had withdrawal of supportive therapies following family discussion. Our observations are AHA level 5 (retrospective case series) evidence that vasopressin administration may be beneficial during prolonged pediatric cardiac arrest. Such reports should pave the way for prospective clinical trials comparing vasopressor medications in the setting of pediatric cardiac arrest.

Topics: Cardiopulmonary Resuscitation; Child, Preschool; Female; Heart Arrest; Humans; Infant; Male; Retrospective Studies; Time Factors; Vasoconstrictor Agents; Vasopressins

Topics: Epinephrine; Heart Arrest; Humans; Vasopressins

Topics: Animals; Disease Models, Animal; Epinephrine; Heart Arrest; Hemodynamics; Swine; Vasopressins; Ventricular Fibrillation

The use of vasopressin instead of adrenaline/epinephrine during resuscitation improves vital organ perfusion, but the effects on mesenteric perfusion following successful resuscitation are not fully evaluated. The present study was designed to compare the effects of vasopressin and adrenaline/epinephrine, given to rats during resuscitation from ventricular fibrillation, on to mesenteric ischaemia, as determined by intestinal mucosal tonometer pCO(2) during the postresuscitation period.. Male Sprague-Dawley rats (n=28) were allocated randomly to receive vasopressin (0.8 U/kg) or adrenaline/epinephrine (90 microg/kg) after 5 min of ventricular fibrillation. Precordial chest compression was initiated 4 min after the start of ventricular fibrillation, continued for 4 min, and followed by defibrillation. Seven of 14 (vasopressin) and 12 of 14 (adrenaline/epinephrine) rats were successfully defibrillated (P=0.10, Fisher's exact test) and observed for 60 min. Intestinal mucosal tonometer pCO(2) measurements before cardiac arrest and 15, 30, and 60 min following return of spontaneous circulation were 47+/-3, 73+/-8, 63+/-7, and 56+/-6 mmHg in the vasopressin group and 48+/-5, 78+/-7, 67+/-6, and 62+/-6 mmHg in the adrenaline/epinephrine group (P<0.05 at 60 min between vasopressin and adrenaline/epinephrine). Right atrial hemoglobin oxygen saturations at these time points were 73+/-5, 51+/-12, 58+/-11, and 63+/-5% in the vasopressin group and 76+/-7, 44+/-10, 52+/-10 and 54+/-8% in the adrenaline/epinephrine group (P<0.05 at 60 min between vasopressin and adrenaline/epinephrine).. We conclude that in this rat model the administration of vasopressin instead of adrenaline/epinephrine for CPR tends to be associated with lower resuscitation success, but less mesenteric ischaemia during the postresuscitation period in successfully resuscitated rats.

Topics: Adrenergic Agonists; Animals; Blood Gas Analysis; Carbon Dioxide; Epinephrine; Heart Arrest; Ischemia; Male; Manometry; Mesentery; Models, Animal; Rats; Rats, Sprague-Dawley; Resuscitation; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

In experimental cardiopulmonary resuscitation (CPR) aortic balloon occlusion, vasopressin, and hypertonic saline dextran administration improve cerebral blood flow. Free radical scavenger alpha-phenyl-N-tert-butyl-nitrone (PBN) and cyclosporine-A (CsA) alleviate neuronal damage after global ischemia. Combining these treatments, we investigated neurological outcome after experimental cardiac arrest.. : Thirty anesthetized piglets, randomly allocated into three groups, were subjected to 8 min of ventricular fibrillation followed by 5 min of closed-chest CPR. The combined treatment (CT) group received all the above-mentioned modalities; group B was treated with balloon occlusion and epinephrine; and group C had sham balloon occlusion with epinephrine. Indicators of oxidative stress (8-iso-PGF(2 alpha)), inflammation (15-keto-dihydro-PGF(2 alpha)), energy crisis (hypoxanthine and xanthine), and anoxia/hypoxia (lactate) were monitored in jugular bulb venous blood. Neurological outcome was evaluated 24 h after CPR.. : Restoration of spontaneous circulation (ROSC) was more rapidly achieved and neurological outcome was significantly better in the CT group, although there was no difference in coronary perfusion pressure between groups. The jugular venous PCO2 and cerebral oxygen extraction ratio were lower in the CT group at 5-15 min after ROSC. Jugular venous 8-iso-PGF(2 alpha) and hypoxanthine after ROSC were correlated to 24 h neurological outcome. : A combination of cerebral blood flow promoting measures and administration of alpha-phenyl-N-tert-butyl-nitrone and cyclosporine-A improved 24 h neurological outcome after 8 min of experimental normothermic cardiac arrest, indicating an ongoing neuronal injury in the reperfusion phase.

Topics: Angioplasty, Balloon, Coronary; Animals; Cardiopulmonary Resuscitation; Cerebrovascular Circulation; Cyclosporine; Dinoprost; Epinephrine; Free Radical Scavengers; Heart Arrest; Hypoxanthine; Lactic Acid; Nervous System Diseases; Saline Solution, Hypertonic; Swine; Treatment Outcome; Vasoconstrictor Agents; Vasopressins; Xanthine

Topics: Advanced Cardiac Life Support; Algorithms; American Heart Association; Anti-Arrhythmia Agents; Cardiopulmonary Resuscitation; Electric Countershock; Emergency Medical Services; Epinephrine; Evidence-Based Medicine; Heart Arrest; Humans; Practice Guidelines as Topic; Respiration, Artificial; Sympathomimetics; United States; Vasoconstrictor Agents; Vasopressins

Topics: Aftercare; Anti-Inflammatory Agents; Cardiotonic Agents; Dopamine; Evidence-Based Medicine; Heart Arrest; Humans; Hypothermia, Induced; Respiration, Artificial; Resuscitation; Steroids; Time Factors; Vasoconstrictor Agents; Vasopressins

Topics: Adult; Age Factors; Child; Epinephrine; Evidence-Based Medicine; Heart Arrest; Humans; Infant; Resuscitation; Shock; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Exogenous vasopressin is a promising vasopressor when blood pressure is critically threatened, but the role of endogenous vasopressin during cardiopulmonary resuscitation (CPR) is unknown. We assessed the role of endogenous versus exogenous vasopressin in a porcine open chest CPR model. Seven minutes before induction of cardiac arrest, seven pigs received 10 microg/kg of a selective vasopressin V(1)-receptor-antagonist (Blocked Vasopressin group); another 12 pigs in two groups received saline administration only. After 4 min of untreated ventricular fibrillation followed by 3 min of basic life support CPR, six animals received 0.8 U/kg vasopressin (Exogenous Vasopressin group), whereas the blocked vasopressin group (n = 7), and the remaining six animals received saline placebo only (Endogenous Vasopressin group). Defibrillation was attempted after 14 min of CPR. During basic life support CPR, left ventricular myocardial blood flow was significantly (P < 0.05) decreased in the Blocked Vasopressin group compared with the Exogenous Vasopressin group and Endogenous Vasopressin group (42 +/- 5 compared with 64 +/- 6 and 66 +/- 6 mL x min(-1) x 100g(-1)). Left ventricular myocardial blood flow was significantly decreased in the Blocked Vasopressin group versus Exogenous Vasopressin group versus Endogenous Vasopressin group 90 s and 5 min after drug administration, respectively (38 +/- 4 and 27 +/- 3 vs 145 +/- 32 and 110 +/- 12 vs 62 +/- 4 and 56 +/- 6 mL x min(-1) x 100g(-1), respectively). None of seven Blocked Vasopressin animals, six of six Exogenous Vasopressin pigs, and six of six Endogenous Vasopressin swine had return of spontaneous circulation after 14 min of cardiac arrest including 10 min of CPR (P < 0.05). In conclusion, pigs with blocked endogenous vasopressin had poor coronary perfusion pressure and left ventricular myocardial blood flow during open chest CPR, and could not be successfully resuscitated. All pigs with effective endogenous vasopressin or pigs with effective endogenous vasopressin and additional exogenous vasopressin had good left ventricular myocardial blood flow during experimental CPR, and survived the 1-h postresuscitation phase. We conclude that endogenous vasopressin is an adjunct vasopressor to epinephrine and may serve as a back-up regulator to maintain cardiocirculatory homeostasis.

Topics: Animals; Cardiopulmonary Resuscitation; Coronary Circulation; Epinephrine; Heart Arrest; Hemodynamics; Myocardium; Swine; Vasopressins; Ventricular Function, Left

Topics: Clinical Protocols; Emergency Medical Services; Epinephrine; Heart Arrest; Humans; Patient Selection; Resuscitation; Survival Analysis; Time Factors; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

The intraosseous route is an emergency alternative for the administration of drugs and fluids if vascular access cannot be established. However, in hemorrhagic shock or after vasopressors are given during resuscitation, bone marrow blood flow may be decreased, thus impairing absorption of intraosseously administered drugs. In this study, we evaluated the effects of vasopressin vs. high-dose epinephrine in hemorrhagic shock and cardiac arrest on bone marrow blood flow.. Prospective, randomized laboratory investigation that used an established porcine model for measurement of hemodynamic variables and organ blood flow.. University hospital laboratory.. Fourteen pigs weighing 30 +/- 3 kg.. Radiolabeled microspheres were injected to measure bone marrow blood flow during a prearrest control period and during hypovolemic shock produced by rapid hemorrhage of 35% of the estimated blood volume. In the second part of the study, ventricular fibrillation was induced; after 4 mins of untreated cardiac arrest and 4 mins of standard cardiopulmonary resuscitation, a bolus dose of either 200 microg/kg epinephrine (n = 6) or 0.8 units/kg vasopressin (n = 6) was administered. Defibrillation was attempted 2.5 mins after drug administration, and blood flow was assessed again at 5 and 30 mins after successful resuscitation.. Mean +/- sem bone marrow blood flow decreased significantly during induction of hemorrhagic shock from 14.4 +/- 4.1 to 3.7 +/- 1.8 mL.100 g-1.min-1 in the vasopressin group and from 18.2 +/- 4.0 to 5.2 +/- 1.0 mL.100 g-1.min-1 in the epinephrine group (p =.025 in both groups). Five minutes after return of spontaneous circulation, mean +/- sem bone marrow blood flow was 3.4 +/- 1.1 mL.100 g-1.min-1 after vasopressin and 0.1 +/- 0.03 mL.100 g-1.min-1 after epinephrine (p =.004 for vasopressin vs. epinephrine). At the same time, bone vascular resistance was significantly (p =.004) higher in the epinephrine group when compared with vasopressin (1455 +/- 392 vs. 43 +/- 19 mm Hg. mL-1.100 g.min, respectively).. Bone blood flow responds actively to both the physiologic stress response of hemorrhagic shock and vasopressors given during resuscitation after hypovolemic cardiac arrest. In this regard, bone marrow blood flow after successful resuscitation was nearly absent after high-dose epinephrine but was maintained after high-dose vasopressin. These findings emphasize the need for pressurized intraosseous infusion techniques, because bone marrow blood flow may not be predictable during hemorrhagic shock and drug therapy.

Topics: Animals; Bone Marrow; Epinephrine; Female; Heart Arrest; Hemodynamics; Infusions, Intraosseous; Microspheres; Resuscitation; Shock; Swine; Vasoconstrictor Agents; Vasopressins

The purpose of this study was to investigate the effects of vasopressin versus epinephrine, and both drugs combined, in a porcine model of simulated adult asphyxial cardiac arrest.. At approximately 7 minutes after the endotracheal tube had been clamped, cardiac arrest was present in 24 pigs and remained untreated for another 8 minutes. After 4 minutes of basic life support cardiopulmonary resuscitation, pigs were randomly assigned to receive, every 5 minutes, either epinephrine (45, 200, or 200 microgram/kg; n=6); vasopressin (0.4, 0.8, or 0.8 U/kg; n=6); or epinephrine combined with vasopressin (high-dose epinephrine/vasopressin combination, microgram/kg and U/kg: 45/0.4, 200/0.8, or 200/0.8; n=6; optimal-dose epinephrine/vasopressin combination, 45/0.4, 45/0.8, or 45/0.8; n=6). Mean+/-SEM coronary perfusion pressure was significantly (P<0.05) higher 90 seconds after high- or optimal-dose epinephrine/vasopressin combinations versus vasopressin alone and versus epinephrine alone (37+/-10 versus 25+/-7 versus 19+/-8 versus 6+/-3 mm Hg; 42+/-6 versus 40+/-5 versus 21+/-5 versus 14+/-6 mm Hg; and 39+/-6 versus 37+/-4 versus 9+/-3 versus 12+/-4 mm Hg, respectively). Six of 6 high-dose, 6 of 6 optimal-dose vasopressin/epinephrine combination, 0 of 6 vasopressin, and 1 of 6 epinephrine pigs had return of spontaneous circulation (P<0.05).. Epinephrine combined with vasopressin, but not epinephrine or vasopressin alone, maintained elevated coronary perfusion pressure during cardiopulmonary resuscitation and resulted in significantly higher survival rates in this adult porcine asphyxial model.

Topics: Animals; Asphyxia; Blood Pressure; Cardiopulmonary Resuscitation; Drug Combinations; Epinephrine; Heart; Heart Arrest; Hemodynamics; Kinetics; Myocardial Reperfusion; Survival Rate; Swine; Vasopressins

Topics: Animals; Asphyxia; Epinephrine; Heart Arrest; Hospitalization; Humans; Swine; Vasoconstrictor Agents; Vasopressins

Topics: Heart Arrest; Humans; Resuscitation; Vasoconstrictor Agents; Vasopressins

Topics: Emergency Medical Services; Heart Arrest; Hospitalization; Humans; Time Factors; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

The latest resuscitation guidelines from the American Heart Association expand the scope of emergency care and emphasize interventions with proven safety and usefulness. Here's what new therapies are in, and what gold standards are out because of a lack of strong supporting evidence.

Topics: Cardiopulmonary Resuscitation; Emergency Medical Services; Heart Arrest; Humans; Life Support Care; Practice Guidelines as Topic; Vasoconstrictor Agents; Vasopressins

The American Heart Association does not recommend epinephrine for management of hypothermic cardiac arrest if body core temperature is below 30 degrees C. Furthermore, the effects of vasopressin administration during hypothermic cardiac arrest are totally unknown. This study was designed to assess the effects of vasopressin and epinephrine on coronary perfusion pressure in a porcine model during hypothermic cardiac arrest cardiopulmonary resuscitation (CPR). Pigs were surface-cooled until their body core temperature was 26 degrees C. After 30 min of untreated cardiac arrest, followed by 3 min of basic life support CPR, 15 animals were randomly assigned to receive, at 5-min intervals, either vasopressin (0.4, 0.4, and 0.8 U/kg; n = 5), epinephrine (45, 45, and 200 microg/kg; n = 5), or saline placebo (n = 5). Compared with epinephrine, mean +/- SEM coronary perfusion pressure was significantly higher (P < 0.05) 90 s and 5 min after the first (35+/-4 vs 22+/-3 mm Hg and 37+/-2 vs 16+/-2 mm Hg) and the second vasopressin administration (40+/-5 vs 26+/-5 mm Hg and 36+/-5 vs 18+/-2 mm Hg, respectively). After the third drug administration, coronary perfusion pressure in the epinephrine group increased dramatically and was comparable to vasopressin. In the saline placebo group, coronary perfusion pressure was significantly lower (P < 0.05) than in the vasopressin and epinephrine groups. Six animals treated with epinephrine or vasopressin had transient return of spontaneous circulation, whereas all placebo animals died (P < 0.05). During CPR in severe hypothermia, administration of both vasopressin and epinephrine resulted in significant increases in coronary perfusion pressure when compared with placebo.. Our study was designed to assess the effects of vasopressin and epinephrine in a porcine model simulating cardiac arrest during severe hypothermia. This study demonstrates that the administration of both emergency drugs results in an increased perfusion pressure in the heart.

Topics: Animals; Blood Pressure; Body Temperature; Cardiopulmonary Resuscitation; Coronary Circulation; Epinephrine; Female; Heart Arrest; Hypothermia; Male; Swine; Vasoconstrictor Agents; Vasopressins

Survival after hypovolemic shock and cardiac arrest is dismal with current therapies. We evaluated the potential benefits of vasopressin versus large-dose epinephrine in hemorrhagic shock and cardiac arrest on vital organ perfusion, and the likelihood of resuscitation. In 18 pigs, 35% of the estimated blood volume was withdrawn over 15 min and ventricular fibrillation was induced 5 min later. After 4 min of cardiac arrest and 4 min of standard cardiopulmonary resuscitation, a bolus dose of either 200 microg/kg epinephrine (n = 7), 0.8 unit/kg vasopressin (n = 7), or saline placebo (n = 4) was administered in a blinded, randomized manner. Defibrillation was attempted 2.5 min after drug administration, and all animals were subsequently observed for 1 h without further intervention. Spontaneous circulation was restored in 7 of 7 vasopressin animals, in 6 of 7 epinephrine pigs, and in 0 of 4 placebo swine. At 5 and 30 min after return of spontaneous circulation, median (minimum and maximum) renal blood flow after epinephrine was 2 (0-31), and 2 (0-48) mL. 100 g(-1). min(-1), respectively; and after vasopressin 96 (12-161), and 44 (16-105) mL. 100 g(-1). min(-1), respectively (P: <.01 between groups). Epinephrine animals developed a profound metabolic acidosis by 15 min after return of spontaneous circulation (mean arterial pH, 7.11 +/- 0.01), and by 60 min all epinephrine-treated animals had died. The vasopressin pigs had (P: = 0.015) less acidosis (pH = 7.26+/-0. 04) at corresponding time points, and all survived > or =55 min (P: < 0. 01). In conclusion, treatment of hypovolemic cardiac arrest with vasopressin, but not with large-dose epinephrine or saline placebo, resulted in sustained vital organ perfusion, less metabolic acidosis, and prolonged survival. Based on these findings, clinical evaluation of vasopressin during hypovolemic cardiac arrest may be warranted.. The chances of surviving cardiac arrest in hemorrhagic shock are considered dismal without adequate fluid replacement. However, treatment of hypovolemic cardiac arrest with vasopressin, but not with large-dose epinephrine or saline placebo, resulted in sustained vital organ perfusion and prolonged survival in an animal model of suspended infusion therapy.

Topics: Animals; Blood Gas Analysis; Blood Pressure; Cardiopulmonary Resuscitation; Coronary Circulation; Female; Heart Arrest; Microspheres; Regional Blood Flow; Shock; Survival Analysis; Swine; Vasopressins

Vasopressin is a possible stimulus for both adrenocorticotropin (ACTH) and endothelin-1 release. The aim of this study was to compare plasma concentrations of ACTH, cortisol, and endothelin-1 after epinephrine or vasopressin administration in an experimental animal model of cardiopulmonary resuscitation (CPR).. Prospective, randomized, controlled animal study.. A university research laboratory.. Fourteen 12- to 14-wk-old domestic pigs.. After 4 mins of cardiac arrest and 3 mins of external chest compression, the pigs were randomly assigned to receive either 0.045 mg/kg epinephrine (n = 7) or 0.4 units/kg vasopressin (n = 7). At 5 mins after drug administration, defibrillation was attempted.. Coronary perfusion pressure, ACTH, cortisol, and endothelin-1 were measured before cardiocirculatory arrest, during CPR before drug administration, and at 90 secs and 5 mins after drug administration. Coronary perfusion pressure was comparable between groups. All seven animals in the vasopressin group survived, but only one pig in the epinephrine group survived (p = .005). ACTH and cortisol concentrations remained unchanged in epinephrine-treated animals, but increased significantly after vasopressin administration and were significantly higher than in epinephrine-treated animals 5 mins after drug administration. Endothelin-1 concentrations remained unchanged during the study period and were comparable between both groups.. Vasopressin is a potent stimulus for ACTH secretion, but does not trigger endothelin-1 release from vascular cells during cardiac arrest and CPR. The increased plasma cortisol concentrations caused by the enhanced ACTH release after vasopressin may be one factor contributing to the improved outcome repeatedly observed with vasopressin in animal models of CPR.

Topics: Adrenocorticotropic Hormone; Animals; Cardiopulmonary Resuscitation; Disease Models, Animal; Drug Evaluation, Preclinical; Electric Countershock; Endothelin-1; Epinephrine; Heart Arrest; Hemodynamics; Hydrocortisone; Random Allocation; Survival Analysis; Swine; Time Factors; Vasoconstrictor Agents; Vasopressins

This study was designed to compare the effects of vasopressin vs. epinephrine vs. the combination of epinephrine with vasopressin on vital organ blood flow and return of spontaneous circulation in a pediatric porcine model of asphyxial arrest.. Prospective, randomized laboratory investigation using an established porcine model for measurement of hemodynamic variables, organ blood flow, blood gases, and return of spontaneous circulation.. University hospital laboratory.. Eighteen piglets weighing 8-11 kg.. Asphyxial cardiac arrest was induced by clamping the endotracheal tube. After 8 mins of cardiac arrest and 8 mins of cardiopulmonary resuscitation, a bolus dose of either 0.8 units/kg vasopressin (n = 6), 200 microg/kg epinephrine (n = 6), or a combination of 45 microg/kg epinephrine with 0.8 units/kg vasopressin (n = 6) was administered in a randomized manner. Defibrillation was attempted 6 mins after drug administration.. Mean +/- SEM coronary perfusion pressure, before and 2 mins after drug administration, was 13 +/- 2 and 23 +/- 6 mm Hg in the vasopressin group; 14 +/- 2 and 31 +/- 4 mm Hg in the epinephrine group; and 13 +/- 1 and 33 +/- 6 mm Hg in the epinephrine-vasopressin group, respectively (p = NS). At the same time points, mean +/- SEM left ventricular myocardial blood flow was 44 +/- 31 and 44 +/- 25 mL x min-(1) x 100 g(-1) in the vasopressin group; 30 +/- 18 and 233 +/- 61 mL x min(-1) x 100 g(-1) in the epinephrine group; and 36 +/- 10 and 142 +/- 57 mL x min(-1) x 100 g(-1) in the epinephrine-vasopressin group (p < .01 epinephrine vs. vasopressin; p < .02 epinephrine-vasopressin vs. vasopressin). Total cerebral blood flow trended toward higher values after epinephrine-vasopressin (60 +/- 19 mL x min(-1) x 100 g(-1)) than after vasopressin (36 +/- 17 mL x min(-1) x 100 g(-1)) or epinephrine alone (31 +/- 7 mL x min(-1) x 100 g(-1); p = .07, respectively). One of six vasopressin, six of six epinephrine, and four of six epinephrine-vasopressin-treated animals had return of spontaneous circulation (p < .01, vasopressin vs. epinephrine).. Administration of epinephrine, either alone or in combination with vasopressin, significantly improved left ventricular myocardial blood flow during cardiopulmonary resuscitation. Return of spontaneous circulation was significantly more likely in epinephrine-treated pigs than in animals resuscitated with vasopressin alone.

Topics: Adrenergic Agonists; Age Factors; Animals; Asphyxia; Blood Circulation; Blood Gas Analysis; Cerebrovascular Circulation; Coronary Circulation; Disease Models, Animal; Drug Evaluation, Preclinical; Drug Therapy, Combination; Electric Countershock; Epinephrine; Female; Heart Arrest; Heart Ventricles; Hemodynamics; Random Allocation; Resuscitation; Swine; Time Factors; Vasoconstrictor Agents; Vasopressins

Although a benefit of vasopressin when compared with epinephrine was shown during cardiopulmonary resuscitation (CPR) after a short duration of ventricular fibrillation cardiac arrest, the effect of vasopressin during prolonged cardiac arrest with pulseless electrical activity is currently unknown.. Prospective, randomized laboratory investigation using an established porcine model with instrumentation for measurement of hemodynamic variables, vital organ blood flow, blood gases, and return of spontaneous circulation.. University hospital laboratory.. Eighteen domestic pigs.. After 15 mins of cardiac arrest and 3 mins of chest compressions, 18 animals were randomly treated with either 0.8 units/kg vasopressin (n = 9) or 200 microg/kg epinephrine (n = 9).. Compared with epinephrine, vasopressin resulted, at both 90 secs and 5 mins after drug administration, in significantly higher (p < .05) median (25th-75th percentiles) left ventricular myocardial blood flow (120 [range, 96-193] vs. 54 [range, 11-92] and 56 [range, 41-80] vs. 21 [range, 11-40] mL/min/100 g, respectively) and total cerebral blood flow (85 [78-102] vs. 24 [18-41] and 50 [44-52] vs. 8 [5-23] mL/min/100 g, respectively). Spontaneous circulation was restored in eight of nine animals in the vasopressin group and in one of nine animals in the epinephrine group (p = .003).. Compared with a maximum dose of epinephrine, vasopressin significantly increased left ventricular myocardial and total cerebral blood flow during CPR and return of spontaneous circulation in a porcine model of prolonged cardiac arrest with postcountershock pulseless electrical activity.

Topics: Animals; Cerebrovascular Circulation; Coronary Circulation; Electric Countershock; Epinephrine; Heart Arrest; Hemodynamics; Prospective Studies; Random Allocation; Resuscitation; Swine; Time Factors; Vasoconstrictor Agents; Vasopressins

In animal models, vasopressin improves short-term outcome after cardiopulmonary resuscitation (CPR) for ventricular fibrillation compared to placebo, and improves myocardial and cerebral hemodynamics during CPR compared to epinephrine. This study was designed to test the hypothesis that vasopressin would improve 24-h neurologically intact survival compared to epinephrine. After a 2-min untreated ventricular fibrillation interval followed by 6 min of simulated bystander CPR, 35 domestic swine (weight, 25+/-1 kg) were randomly provided with a single dose of vasopressin (20 U or approximately 0.8 U kg(-1) intravenously) or with epinephrine (0.02 mg kg(-1) intravenously every 5 min). Ten minutes after initial medication administration (18 min after induction of ventricular fibrillation), standard advanced life support was provided, starting with defibrillation. Animals that were successfully resuscitated received 1 h of intensive care support and were observed for 24 h. Coronary perfusion pressures were higher in the vasopressin group 2 and 4 min after vasopressin administration (28+/-2 versus 18+/-1 mm Hg, P<0.01, and 26+/-3 versus 18+/-2 mm Hg, P<0.05, respectively). The vasopressin group tended to be successfully defibrillated on the first attempt more frequently (8/18 versus 3/17, P = 0.15). Return of spontaneous circulation (ROSC) was attained in 12/18 (67%) vasopressin-treated pigs versus 8/17 (47%) epinephrine-treated pigs, P = 0.24. Twenty-four hour neurologically normal survival occurred in 11/18 (61%) versus 7/17 (41%), respectively, P = 0.24. In conclusion, vasopressin administration during CPR improved coronary perfusion pressure, but did not result in statistically significant outcome improvement.

Topics: Animals; Cardiopulmonary Resuscitation; Disease Models, Animal; Epinephrine; Heart Arrest; Hemodynamics; Random Allocation; Reference Values; Survival Rate; Swine; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Vasopressin (antidiuretic hormone) seems a promising alternative to epinephrine for cardiopulmonary resuscitation (CPR) in cardiac arrest victims, mediating a pronounced blood flow shift toward vital organs. We evaluated the effects of small-dose dopamine on splanchnic blood flow and renal function after successful resuscitation with this potent vasoconstrictor in an established porcine CPR model. After 4 min of cardiac arrest and 3 min of CPR, animals received 0.4 U/kg vasopressin and were continuously infused with either dopamine 4 microg x kg(-1) x min(-1) (n = 6), or saline placebo (n = 6). Defibrillation was performed 5 min after drug administration; all animals were observed for 6 h after return of spontaneous circulation. During the postresuscitation phase, average mean +/- SD superior mesenteric artery blood flow was significantly (P = 0.002) higher in the dopamine group compared with the placebo group (1185+/-130 vs 740+/-235 mL/min), whereas renal blood flow was comparable between groups (255+/-40 vs 250+/-85 mL/min). The median calculated glomerular filtration rate had higher values in the dopamine group (70-120 mL/min) than in the placebo group (40-70 mL/min; P = 0.1 at 0 min and P = 0.08 at 360 min). We conclude that small-dose dopamine administration may be useful in improving superior mesenteric artery blood flow and renal function after successful resuscitation with vasopressin.. Long-term survival after cardiac arrest may be determined by the ability to ensure adequate organ perfusion during cardiopulmonary resuscitation and in the postresuscitation phase. In this regard, small-dose dopamine improved postresuscitation blood flow to the mesenteric bed when vasopressin was used as an alternative vasopressor in an animal model of cardiac arrest.

Topics: Animals; Blood Gas Analysis; Cardiopulmonary Resuscitation; Cardiotonic Agents; Disease Models, Animal; Dopamine; Dose-Response Relationship, Drug; Female; Heart Arrest; Intestines; Kidney; Male; Mesenteric Artery, Superior; Renal Agents; Splanchnic Circulation; Swine; Vasoconstrictor Agents; Vasopressins

Although vasopressin increases vital organ blood flow during cardiopulmonary resuscitation (CPR), endocardial perfusion remains suboptimal. This study was designed to assess the effects of vasopressin versus a combination of vasopressin and nitroglycerin on vital organ blood flow in a porcine model of CPR. After 4 min of cardiac arrest, and 3 min of closed-chest compressions, 14 animals were randomly treated with either 0.4 U/kg vasopressin (n = 7) or 0.4 U/kg vasopressin combined with 5 microg/kg nitroglycerin (n = 7). Coronary and cerebral perfusion pressure as well as left ventricular myocardial blood flow was comparable between groups throughout the experiment. Ninety seconds after drug administration, vasopressin combined with nitroglycerin resulted in comparison with vasopressin alone in significantly higher mean (+/- standard error of the mean) left ventricular endocardial blood flow (78+/-7 vs 51+/-5 ml x min(-1) x 100 g(-1); P < 0.05), and a significantly higher endocardial/epicardial perfusion ratio (0.93+/-0.09 vs 0.57+/-0.06; P < 0.05). Seven of seven animals in the vasopressin group, and four of seven animals in the vasopressin and nitroglycerin group (NS) were resuscitated successfully and survived the 2-h observation period. We conclude that, when compared with vasopressin therapy alone, combined vasopressin and nitroglycerin improved endocardial perfusion significantly immediately after drug administration during CPR.

Topics: Analysis of Variance; Animals; Cardiopulmonary Resuscitation; Coronary Circulation; Disease Models, Animal; Endocardium; Female; Heart Arrest; Hemodynamics; Male; Nitroglycerin; Random Allocation; Swine; Vasoconstrictor Agents; Vasodilator Agents; Vasopressins

Topics: Adrenergic Agonists; Adult; Angiotensin II; Animals; Cardiopulmonary Resuscitation; Child; Epinephrine; Heart Arrest; Humans; Vasoconstrictor Agents; Vasopressins

Both epinephrine (Epi) and vasopressin (VP) increase coronary perfusion pressure (CPP) when administered during cardiac arrest. Given their different mechanisms of action we tested the hypothesis that during cardiopulmonary resuscitation (CPR) a combination of VP plus Epi would be superior to either agent alone. Epi(40 microg/kg), VP(0.3 U/kg) and the combination of both agents were assessed in a porcine model of ventricular fibrillation (VF). Maximum CPP (diastolic aortic-right atrial pressures) during CPR was similar among the groups but the time course of action was different in each group: with Epi + VP the increase in CPP was significantly more rapid than with VP alone whereas the CPP remained significantly higher for a longer periods of time with VP or VP + Epi versus Epi alone. Left ventricular blood flow (ml/min per g) determined during CPR two min after drug administration was similar between groups: Epi 1.06 +/- 0.16; VP 0.82 +/- 0.26; Epi + VP 0.83 +/- 0.14 (P = N.S.). Post drug administration. 2 min, cerebral blood flow (ml/min per g) in the VP group (0.76 +/- 0.15) was more than two times higher compared with Epi alone (Epi:0.30 +/- 0.08, P < 0.01 versus VP) and Epi plus VP (Epi + VP:0.23 +/- 0.03, P < 0.01 versus VP). We conclude that combination of VP + Epi during cardiac arrest results in a more rapid rise in CPP when compared with VP alone and a more sustained elevation in CPP than observed with Epi alone. Thus, the synergistic effects of these two potent vasopressor agents may be of benefit during CPR.

Topics: Adrenergic Agonists; Animals; Aorta; Atrial Function, Right; Blood Pressure; Cardiac Output; Cardiopulmonary Resuscitation; Cerebrovascular Circulation; Drug Combinations; Drug Synergism; Epinephrine; Female; Heart Arrest; Heart Atria; Random Allocation; Swine; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation; Ventricular Function, Left

Successful outcomes after cardiopulmonary resuscitation remain disappointingly infrequent, in animal studies, administration of exogenous vasopressin during closed- and open-chest cardiopulmonary resuscitation has recently been shown to be more effective than optimal doses of epinephrine in improving vital organ blood flow.. To describe the clinical effects and outcomes of administering vasopressin to patients in cardiac arrest refractory to current medical therapies.. Case reports.. University hospital.. 8 adults with in-hospital cardiac arrest.. After intravenous epinephrine (administered according to American Heart Association guidelines) and defibrillation efforts had failed, patients in cardiac arrest who were having cardiopulmonary resuscitation received 40 U of vasopressin intravenously and then defibrillation.. Return of spontaneous circulation and hospital discharge rates.. After administration of vasopressin, spontaneous circulation was promptly restored in all patients. Three patients were discharged from the hospital with intact neurologic function; the other five lived for between 30 minutes and 82 hours.. In the presence of ventricular fibrillation with severe hypoxia and acidosis, vasopressin seems to be more potent and effective than adrenergic vasopressors for restoring spontaneous cardiovascular function. These results do not justify the widespread use of vasopressin for refractory cardiac arrest. However, on the basis of these cases, further studies comparing vasopressin with epinephrine are warranted in an effort to improve the currently dismal prognosis of patients after cardiac arrest.

Topics: Adult; Aged; Cardiopulmonary Resuscitation; Combined Modality Therapy; Female; Heart Arrest; Humans; Male; Middle Aged; Vasopressins; Ventricular Fibrillation

This study was designed to assess whether median frequency of ventricular fibrillation (VF) correlates with myocardial blood flow and defibrillation success during cardiopulmonary resuscitation (CPR) after epinephrine or vasopressin administration.. After 4 min of VF and 3 min of CPR, 14 pigs received 0.045 mg/kg epinephrine or 0.4 U/kg vasopressin. Using radio-labeled microspheres, median myocardial blood flow during CPR before, and 90 s and 5 min after drug administration (DA) was 15.5 (12.6, 23.1; 25th percentile, 75th percentile), 26.4 (18.5, 29.1), 16.9 (14.9, 19.1) mL min-1 100 g-1, respectively, in the epinephrine, and 16.9 (15.4, 18.9), 48.1 (36.9, 68.9) (P < 0.05 vs. before DA), 52.3 (38.5, 65.0) mL min-1 100 g-1, respectively, in the vasopressin group. Using spectral analysis of VF, median frequency of VF was 11.0 (10.7, 11.8), 11.3 (9.6, 13.1), 10.2, (8.8, 11.4) Hz, respectively, in the epinephrine, and 10.1 (10.0, 10.5), 11.7 (11.1, 14.2) (P < 0.05 vs. before DA), 13.2 (11.5, 13.9) Hz, respectively, in the vasopressin group at the same points in time. Median frequency correlates significantly with myocardial blood flow in the epinephrine (n = 21); rs = 0.772; P < 0.001) and in the vasopressin group (n = 21; rs = 0.905; P < 0.001). Median fibrillation frequency before the first defibrillation was 13.0 (12.2, 13.2) Hz in resuscitated (n = 8) and 9.2 (8.3, 10.2) Hz (n = 6) in non-resuscitated animals (P < 0.01).. We conclude that median frequency of VF reflects myocardial blood flow and the chance of successful defibrillation during closed-chest CPR after vasopressor treatment in a porcine model of VF.

Topics: Adrenergic Agonists; Animals; Blood Pressure; Carbon Dioxide; Cardiopulmonary Resuscitation; Coronary Circulation; Disease Models, Animal; Electrocardiography; Epinephrine; Heart Arrest; Microspheres; Oxygen; Potassium; Signal Processing, Computer-Assisted; Sodium; Swine; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

The administration of vasopressin during cardiopulmonary resuscitation (CPR) provides significantly more vital organ blood flow when compared with epinephrine during cardiac arrest in pigs. The effects of this potent vasoconstrictor on postresuscitation cardiovascular function remain unknown. The purpose of this study was to compare the effects of vasopressin and epinephrine on cardiovascular function in the postresuscitation phase after CPR.. Prospective, randomized, experimental study.. University research laboratory.. Domestic pigs, 12 to 14 wks of age.. Sixteen pigs were randomly allocated to receive either 0.045 mg/kg of epinephrine or 0.4 U/kg of vasopressin after 4 mins of cardiac arrest.. Hemodynamics, left ventricular contractility, and myocardial blood flow were measured for an interval of 240 mins after successful CPR. Differences between animals treated with epinephrine vs. vasopressin were most pronounced 15 mins after restoration of spontaneous circulation. At this time, mean aortic pressure was 64 +/- 6 (SEM) mm Hg in the epinephrine group and 84 +/- 6 mm Hg (p < .05) in the vasopressin group. Systemic vascular resistance was 1285 +/- 72 dyne.sec/cm5 in the epinephrine group and 2314 +/- 130 dyne.sec/cm5 (p < .001) in the vasopressin group. Cardiac index was 140 +/- 9 mL/min/kg in animals treated with epinephrine and 99 +/- 9 mL/min/kg (p < .01) in animals treated with vasopressin. Myocardial contractility (dp/ dtmax/P) was 52.8 +/- 3.4/sec with epinephrine as compared with 36.3 +/- 2.9 sec-1 (p < .01) with vasopressin. Left ventricular epicardial blood flow was 241 +/- 35 mL/min/100 g with epinephrine and 142 +/- 22 mL/min/100 g (p < .05) with vasopressin. Four hours after CPR, no significant differences were observed between groups.. In the early postresuscitation phase, vasopressin provided higher systemic blood pressures and there was a reversible depressant effect on myocardial function when compared with epinephrine. Overall cardiovascular function was not irreversibly or critically impaired after the administration of vasopressin in this pig model of cardiac arrest.

Topics: Animals; Cardiopulmonary Resuscitation; Coronary Circulation; Epinephrine; Heart Arrest; Hemodynamics; Models, Biological; Myocardial Contraction; Swine; Vasopressins

This study was designed to assess the interference by closed-chest cardiopulmonary resuscitation (CPR) on the ventricular fibrillation (VF) ECG signal in a porcine model of cardiac arrest and to elucidate which variable of VF spectral analysis reflects best myocardial blood flow and resuscitation success during CPR. Fourteen domestic pigs were allocated to receive either 0.4 U/kg vasopressin (n = 7) or 10 ml saline (n = 7) after 4 min of VF and 3 min of CPR. Using radiolabeled microspheres, myocardial blood flow was determined during CPR before, and 90 s and 5 min after, drug administration. Using spectral analysis of VF, the median frequency, dominant frequency, edge frequency and amplitude of VF were determined simultaneously and before the first defibrillation attempt. Using filters in order to specify frequency ranges, stepwise elimination of mechanical artifacts resulting from CPR revealed that at a frequency bandpass of 4.3-35 Hz, median fibrillation frequency has a sensitivity, specificity, positive and negative predictive value of 100% to differentiate between resuscitated and non-resuscitated animals. The best correlation between myocardial blood flow and fibrillation frequency was found at a median frequency range of 4.3-35 Hz. We conclude that spectral analysis of VF can provide reliable information relating to successful resuscitation. In this model after elimination of oscillations due to mechanical CPR, median fibrillation frequency best reflects the probability of resuscitation success.

Topics: Analysis of Variance; Animals; Cardiopulmonary Resuscitation; Coronary Circulation; Electrocardiography; Fourier Analysis; Heart Arrest; Hemodynamics; Microspheres; Resuscitation; Swine; Vasoconstrictor Agents; Vasopressins; Ventricular Fibrillation

Vasopressin (VP) levels were evaluated by radioimmunoassay (RIA) in the arterial (A), peripheral (Vp) and jugular (Vj) vein blood and in CSF in 102 patients with brain tumors. In 60 cases the patients' state was complicated by brain edema (BE) and hemodynamic disturbances (HDD). The obtained data revealed significantly higher VP levels: 1) in A, Vp and CSF in patients with BE (Group A) in comparison with patients without BE (Group B), 2) in Vj in patients with HDD only (Group Bc) and 3) in Vp in patients with HDD and BE (Group Ac) in comparison with Group Bc (p < 0.05). There were marked extremely high VP levels in Vj in patients with severe haemorrhage, tachycardia and high blood pressure (BP) and in CSF in patients with tachycardia, high BP and cardiac arrest (p < 0.05 correspondingly in each of the cases). Our results on a clinical basis confirmed CSF VP influence on BE development. We also confirmed the neurohumoral (through blood) and neurotransmitter (possibly through CSF and/or vasopressinergic pathways) VP influences on cardiovascular regulation mechanisms. We content that this is a pathogenetic basis for application of VP direct or indirect antagonists for preventing and treating brain edema in neurosurgical patients.

Topics: Adolescent; Adult; Aged; Blood-Brain Barrier; Brain Edema; Brain Neoplasms; Cerebral Hemorrhage; Child; Child, Preschool; Female; Heart Arrest; Hemodynamics; Humans; Hypertension; Male; Middle Aged; Postoperative Complications; Radioimmunoassay; Synaptic Transmission; Tachycardia; Vasopressins

The study of renin-angiotensin-aldosterone (RAA) and vasopressin (VP) systems in neurosurgical patients with brain tumors and brain edema (BE) had revealed an excessive activity of these systems with secondary hyperaldosteronism especially with BE that proves the pathogenetic role of these systems. Measurement of Aldosterone (Ald) in CSF may serve as a diagnostic test to help manage the patient's clinical condition. Mechanisms of Ald penetration in CSF assumed to be the result of blood-brain-barrier (BBB) destruction (especially in astrocytomas) and/or the mediation by neuropeptides (for example increasing activity of VP V1-receptors). Results serve as a basis for application of the neuropeptide and hormone antagonists and inhibitors on all stages of cascade reactions taking part in the water and sodium retention.

Topics: Adolescent; Adult; Aged; Aldosterone; Astrocytoma; Blood-Brain Barrier; Brain Edema; Brain Neoplasms; Cerebral Hemorrhage; Child; Child, Preschool; Female; Heart Arrest; Hemodynamics; Humans; Hyperaldosteronism; Hypertension; Male; Middle Aged; Postoperative Complications; Prognosis; Radioimmunoassay; Renin-Angiotensin System; Tachycardia; Vasopressins

Based upon the hypothesis that vasopressin (antidiuretic hormone) may increase vascular resistance during ventricular fibrillation, the effects of this potent vasoconstrictor were studied in a porcine model of ventricular fibrillation. Vasopressin therapy was compared to epinephrine by randomly allocating 14 pigs to receive either 0.045 mg/kg of epinephrine (n = 7) or 0.8 U/kg of vasopressin (n = 7) after 4 min of ventricular fibrillation and 3 min of open-chest cardiopulmonary resuscitation. During cardiopulmonary resuscitation, myocardial blood flow before and 90 s and 5 min after drug administration was 57 +/- 11, 84 +/- 11, and 59 +/- 9 mL.min-1 x 100 g-1 (mean +/- SEM) in the epinephrine group, and 61 +/- 5, 148 +/- 26, and 122 +/- 22 mL.min-1 x 100 g-1 in the vasopressin group (P < 0.05 at 90 s and 5 min). At the same times, mean cardiac index was not significantly different between the groups. After drug administration, coronary venous PCO2 was significantly higher and coronary venous pH was significantly lower in the epinephrine as compared to the vasopressin group. All pigs in both groups were resuscitated and survived the 2-h observation period. We conclude that vasopressin improves vital organ perfusion during ventricular fibrillation and cardiopulmonary resuscitation. Vasopressin seems to be at least as effective as epinephrine in this pig model of ventricular fibrillation.

Topics: Acid-Base Equilibrium; Animals; Carbon Dioxide; Cardiopulmonary Resuscitation; Epinephrine; Heart Arrest; Hemodynamics; Hydrogen-Ion Concentration; Oxygen; Regional Blood Flow; Swine; Vasopressins

The effectiveness and reliability of long-term control of circulatory stability in brain-dead patients by combined administration of vasopressin and catecholamine was examined in detail. Twenty-five patients were divided into three groups according to the dose of vasopressin. The first group (n = 10) received no vasopressin, the second group (n = 2) an antidiuretic dose (0.1-0.4 U/hr), and the third group (n = 13) a pressor dose (1-2 U/hr), respectively. Patients given no vasopressin or an antidiuretic dose demonstrated circulatory deterioration and cardiac arrest within a short time after brain death, despite administration of a large dose of epinephrine. All patients with a pressor dose of vasopressin, however, demonstrated stable circulation as long as vasopressin and epinephrine were administered. Five patients in whom stable circulation was maintained by this technique were randomly chosen from the third group and studied under the following four conditions: (1) neither vasopressin nor epinephrine; (2) vasopressin only; (3) epinephrine only; and (4) both vasopressin and epinephrine. Compared with the controls (neither vasopressin nor epinephrine), vasopressin only increased the total peripheral resistance index, whereas epinephrine alone increased the cardiac index. Combined administration, however, raised the mean arterial blood pressure significantly by markedly increasing the total peripheral resistance index and cardiac index. Finally, in four brain-dead patients also randomly chosen from the third group, epinephrine, norepinephrine, and dopamine were compared in their circulatory effects with a pressor dose of vasopressin. Epinephrine increased both the total peripheral resistance index and cardiac index, whereas norepinephrine increased the total peripheral resistance index, compared with the baseline (no catecholamine). The required dose of norepinephrine, however, was four times that of epinephrine. The major effect of dopamine was to increase the cardiac index. We conclude that a pressor dose of vasopressin plays a central role in circulatory stabilization of brain-dead patients, and that long-term maintenance of stable circulation for a desired length of time is possible by the combined use of vasopressin and a catecholamine. Individually, catecholamines exhibit characteristic differences. Epinephrine has significant effects on both peripheral vessels and the heart, whereas norepinephrine keeps the circulation stable by increasing the total

Topics: Blood Circulation; Blood Pressure; Brain Death; Catecholamines; Dopamine; Epinephrine; Heart Arrest; Humans; Norepinephrine; Random Allocation; Time Factors; Vasopressins; Water-Electrolyte Balance

Diabetes insipidus following cardiac arrest and hypoxemic encephalopathy occurred in two patients. In both, severe hypoxemic brain damage was followed within three days by clinical and laboratory features of diabetes insipidus, which were corrected by administration of exogenous vasopressin. Hypothalamic injury resulting in diabetes insipidus should be considered in the differential diagnosis of polyuria and dehydration occurring in critically ill patients who have suffered cardiorespiratory arrest.

Topics: Adult; Diabetes Insipidus; Female; Heart Arrest; Humans; Hypothalamus; Hypoxia; Hypoxia, Brain; Respiratory Insufficiency; Vasopressins

Topics: Animals; Antibodies, Viral; Apnea; Autopsy; Blood; Brain; Carbon Dioxide; Child; Chlorpromazine; Diabetes Insipidus; Fluorescent Antibody Technique; Heart Arrest; Humans; Hydrogen-Ion Concentration; Hyperkinesis; Hypotension; Male; Mice; Oxygen; Rabies; Rabies virus; Seizures; Vasopressins

Seventeen patients bleeding from oesophageal varices were treated by continuous infusion of vasopressin through a catheter inserted percutaneously and positioned in the superior mesenteric artery and in two other patients catheterization proved technically impossible. Bleeding was completely controlled on only four out of 18 occasions in the 17 patients treated. In seven patients, bleeding was controlled for two or more days but then recurred although the infusion was continued with an increased dose of vasopressin. There was a high incidence of complications, including bleeding from the site of catheter insertion in the groin and septicaemias. Sengstaken balloon tamponade and oesophageal transection had to be used to control bleeding in some patients but only six out of 17 survived to leave hospital.

Topics: Adult; Catheterization; Endocarditis, Bacterial; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Heart Arrest; Humans; Injections, Intra-Arterial; Liver Diseases; Male; Meningitis, Pneumococcal; Mesenteric Arteries; Middle Aged; Radiography; Thromboembolism; Vasopressins

Topics: Anesthesia, Inhalation; Atrial Fibrillation; Bradycardia; Female; Halothane; Heart Arrest; Humans; Uterine Prolapse; Vasopressins

Topics: Ammonium Chloride; Animals; Bicarbonates; Blood Flow Velocity; Blood Gas Analysis; Carbon Dioxide; Cyanides; Dogs; Glucagon; Heart Arrest; Heart Failure; Humans; Hydrogen-Ion Concentration; Liver Diseases; Lymph; Oxygen; Oxygen Consumption; Shock, Hemorrhagic; Thoracic Duct; Vasopressins

Topics: Angiotensins; Blood Pressure Determination; Central Nervous System Stimulants; Heart Arrest; Heart Failure; Humans; Hypotension; Pharmacology; Postoperative Care; Postoperative Complications; Shock; Sympathomimetics; Toxicology; Vascular Diseases; Vasopressins; Water-Electrolyte Balance

Topics: Emergencies; Heart Arrest; Heart Massage; Histamine H1 Antagonists; Humans; Hypotension; Infusions, Parenteral; Podiatry; Seizures; Spasm; Tachycardia; Vasopressins; Vocal Cord Paralysis

Topics: Arginine Vasopressin; Heart Arrest; Humans; Vasopressins