Background

Vasopressors are used in Emergency Medicine to treat cardiac arrest, hypotension, and shock. Recent studies have sought to investigate questions around timing, medication choices, and administration of these medications in varying clinical scenarios. The emergency provider must be familiar with the properties of, and indications for, vasopressors in the ED setting. In this journal club summary, we review the evidence on the impact vasopressors have on clinical outcomes.

Articles reviewed

1. Hansen M et al. Time to Epinephrine Administration and Survival from Non-Shockable Out-of-Hospital Cardiac Arrest Among Children and Adults. Circulation. 2018 May 8;137(19):2032-2040.[Full Text]

2. Mentzelopoulos S et al. Vasopressin, Steroids, and Epinephrine and Neurologically Favorable Survival After In-Hospital Cardiac Arrest A Randomized Clinical Trial. JAMA. 2013 Jul 17:310(3):270-9. [Pdf]

3. Acquisto N, Bodkin R and Johnstone C. Medication Errors with Push Dose Pressors in the Emergency Department and Intensive Care Units. Am J Emerg Med. 2017 Dec;35(12): 1964-1965.[Pubmed]

4. Schwartz M, Ferreira J and Aaronson P. The Impact of Push-Dose Phenylephrine Use on Subsequent Preload Expansion in the ED Setting. Am J Emerg Med. 2016 Dec;34(12);2419-2422.[Pubmed]

Additional reading

5. Djogovic D et al. Vasopressor and Inotrope Use in Canadian Emergency Departments: Evidence Based Consensus Guidelines. Canadian Journal of Emergency Medicine. 2015 Feb; 17(1): 1-2.[Pdf]

6. Lundin A et al., Drug Therapy in Cardiac Arrest: A Review of the Literature. Eur Heart J Cardiovasc Pharmacother. 2016 Jan; 2(1), 54-75.[Pdf]

HANSEN M. ET AL

This study was a secondary analysis of 32,101 patients treated by EMS for out of hospital cardiac arrest (OOHCA) with an initial unshockable rhythm. Each minute from EMS arrival to administration of epinephrine was associated with a 4% decrease in odds of survivial for adults and a 9% decrease in survival for pediatric patients.

Bottom Line: The data on the effectiveness of epinephrine in cardiac arrest remains variable (most recently a RCT of epinephrine vs placebo in OOHCA showed a survival benefit but no change in favorable neurologic outcome). However, epinephrine is a cornerstone of current guideline-based treatment of cardiac arrest. This paper indicates that minimizing the time to epinephrine in OOHCA may improve survival.

MENTZELOPOULOS S. ET AL

This was a randomized, double-blind, placebo-controlled trial of 268 patients with in-hospital cardiac arrest requiring epinephrine according to guidelines. Patients received either vasopressin/epinephrine for their first five rounds of CPR plus 40 mg methylprednisolone followed by hydrocortisone infusion, or epinephrine only with placebo replacing the vasopressin, methylprednisolone, and hydrocortisone. Outcome measures were ROSC at 20 minutes and survival to hospital discharge. The results showed that the VSE combination group had improved survival to hospital discharge with favorable neurologic status (13.9%) vs the control group (5.1%).

VSE = Vasopressor-steroids-epinephrine combination

Bottom Line: This study must be evaluated in the context of negative evidence regarding vasopressin; the current ACC/AHA guideline specifically recommends against using vasopressin in combination with epinephrine. However, based on this study and one other, they recommend considering VSE in in-hospital cardiac arrest. At the current time use of a VSE protocol for OOHCA (the majority of ED cardiac arrest patients) is not guideline-supported.

SCHWARTZ M. ET AL AND ACQUISTO N. ET AL

This was a single-center retrospective chart review of ED patients who had received push-dose phenylephrine for hypotension. The primary outcome was percent of patients initiated on a continuous vasopressor infusion within 30 minutes after receiving push-dose phenylephrine and the secondary outcome was an assessment of the appropriateness of fluid challenge given to patients. The results showed that 46% of patients who received push-dose phenylephrine were then initiated on continuous vasopressor infusion. The patients who were started on continuous infusions were less likely to be adequately volume challenged. We additionally reviewed an editorial (Acquisito et al.) that emphasized the risk of dosing errors with push-dose pressors.

PHE= PHENYLEPHRINE; CVI = continuous vasopressor infusion

Bottom Line: Push-dose pressors should not replace adequate volume resuscitation in the hypotensive patient, and the ED clinician has to be very cautious with dosing given the possibility of dosing errors.

• Administer epinephrine as soon as possible in OOHCA with an initial unshockable rhythm if indicated by ACLS guidelines.

• Vasopressin/Steroids/Epinephrine combined therapy is not recommended by current guidelines for OOHCA.

• Push dose pressors probably have a role in the ED, but be sure not to neglect adequate volume resuscitation and early initiation of vasopressor infusions if indicated.

Written by Tania Strout, PhD, RN, MS

Edited and Posted by Jeffrey A. Holmes, MD