Cardiologia/Coração/CirurgCardíaca

Investigação multicêntrica, randomizada, publicada ontem na revista The New England Journal of Medicine, buscou comparar o emprego de epinefrina ou vasopressina na terapia vasopressora durante a ressuscitação cardiopulmonar fora do ambiente hospitalar. Após a análise do curso clínico de 1186 pacientes, concluiu-se que a vasopressina é mais efetiva que a epinefrina no tratamento da fibrilação ventricular e da dissociação eletro-mecânica, e que a administração consecutiva de vasopressina e epinefrina pode ser mais eficaz que apenas epinefrina no manejo da parada cardíaca refratária.

The New England Journal of Medicine

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ABSTRACT

Background Vasopressin is an alternative to epinephrine for vasopressor therapy during cardiopulmonary resuscitation, but clinical experience with this treatment has been limited.

Methods 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.

Results 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.

Conclusions 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.

Source Information

From the Department of Anesthesiology and Critical Care Medicine, Leopold-Franzens University, Innsbruck, Austria (V.W., A.C.K., K.H.S., K.H.L.); the Department of Medicine, Division of Cardiology–Pulmonology, Benjamin Franklin Medical Center, Free University, Berlin, Germany (H.R.A.); and the Institute for Theoretical Surgery, Philipps University, Marburg, Germany (H.S.).

Presented in part at the European Resuscitation Council Scientific Congress, Florence, Italy, October 3–5, 2002; and at the Scientific Sessions of the American Heart Association, Orlando, Fla., November 7–11, 2003.

Address reprint requests to Dr. Lindner at the Department of Anesthesiology and Critical Care Medicine, Leopold-Franzens University, Anichstr. 35, 6020 Innsbruck, Austria, or at volker.wenzel@uibk.ac.at.