Exposure to Stress-Dose Steroids and Lethal Septic Shock After In-Hospital Cardiac Arrest: Individual Patient Data Reanalysis of Two Prior Randomized Clinical Trials that Evaluated the Vasopressin–Steroids–Epinephrine Combination Versus Epinephrine Alone

Mentzelopoulos, Spyros D.; Koliantzaki, Iosifina; Karvouniaris, Marios; Vrettou, Charikleia; Karlis, George; Makris, Demosthènes; Zakynthinos, Epaminondas; Sourlas, Sotirios; Aloizos, Stavros; Xanthos, Theodoros; Zakynthinos, Spyros

doi:10.1007/s10557-018-6811-0

“…234,235 Post hoc analysis of these trials found increased benefit of steroids in patients with septic shock. 236 A blinded RCT of 50 patients after CA found no difference between the hydrocortisone and placebo groups in time to shock reversal, shock reversal, good neurological outcome, or survival to discharge. 237…”

Section: Corticosteroidsmentioning

confidence: 99%

Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society

Hirsch,

Abella,

Amorim

et al. 2024

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The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.

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“…Both trials found that the vasopressin-epinephrine-steroid group did better than the comparator group [ 233 , 234 ]. Post hoc analysis of these trials found increased benefit of steroids in patients with septic shock [ 235 ]. A blinded RCT of 50 patients after CA found no difference between the hydrocortisone and placebo groups in time to shock reversal, shock reversal, good neurological outcome, or survival to discharge [ 236 ].…”

Section: Endocrine and Fluids Management In The Icumentioning

confidence: 99%

Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society

Hirsch,

Abella,

Amorim

et al. 2023

Neurocrit Care

3

0

View full text Add to dashboard Cite

The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.

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“…In the context of the vasopressin–steroids–epinephrine (VSE) protocol, early post-ROSC, stress dose steroids may contribute to hemodynamic stabilization, especially in patients requiring high doses of vasopressors (e.g., norepinephrine equivalent ≥ 0.25 μg kg −1 min −1 ) and who have multiple organ failure [ 136 , 137 ]. In addition, a re-analysis of combined data from the two randomized VSE trials reported that exposure to stress dose steroids was associated with a lower risk of post-resuscitation lethal septic shock [ 138 ]. Nevertheless, a more recent, two-center, randomized trial of stress dose steroids (alone) vs. placebo did not confirm any steroid-associated physiological benefit [ 139 ].…”

Section: Circulatory Managementmentioning

confidence: 99%

“…Perhaps the most important to recognize is the patient who is fluid responsive but not fluid tolerant because this patient will be harmed by a fluid responsiveness-based strategy [ 138 ]. As multiple factors can impact the ability of different organs and compartments to accommodate fluids and maintain their function, and different patient phenotypes exist, frequent multimodal and comprehensive clinical assessments of fluid responsiveness and tolerance are necessary.…”

Section: Circulatory Managementmentioning

confidence: 99%

General Critical Care, Temperature Control, and End-of-Life Decision Making in Patients Resuscitated from Cardiac Arrest

Chalkias

¹

,

Adamos

²

,

Mentzelopoulos

³

2023

JCM

Self Cite

2

0

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Cardiac arrest affects millions of people per year worldwide. Although advances in cardiopulmonary resuscitation and intensive care have improved outcomes over time, neurologic impairment and multiple organ dysfunction continue to be associated with a high mortality rate. The pathophysiologic mechanisms underlying the post-resuscitation disease are complex, and a coordinated, evidence-based approach to post-resuscitation care has significant potential to improve survival. Critical care management of patients resuscitated from cardiac arrest focuses on the identification and treatment of the underlying cause(s), hemodynamic and respiratory support, organ protection, and active temperature control. This review provides a state-of-the-art appraisal of critical care management of the post-cardiac arrest patient.

show abstract

Exposure to Stress-Dose Steroids and Lethal Septic Shock After In-Hospital Cardiac Arrest: Individual Patient Data Reanalysis of Two Prior Randomized Clinical Trials that Evaluated the Vasopressin–Steroids–Epinephrine Combination Versus Epinephrine Alone

Abstract: 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.

Cited by 4 publications

References 38 publications

Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society

Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society

Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society

General Critical Care, Temperature Control, and End-of-Life Decision Making in Patients Resuscitated from Cardiac Arrest

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