Background 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.
Methods 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.
Results 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.
Conclusion 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.
Trial Registration clinicaltrials.gov Identifier:
Background In a randomized trial of patients with hip fractures, we previously demonstrated that a hospital-based case manager could increase rates of appropriate osteoporosis treatment to 51% compared with 22% for usual care (P < .001). Alongside that trial, we conducted an economic analysis.
Methods Patients with hip fractures were randomized to usual care (n = 110) or a case manager (n = 110) and followed up for 1 year. Time-motion studies were used to determine intervention costs. From a third-party health care payer perspective and over the patient's remaining lifetime, a Markov decision-analytic model was constructed to determine cost-effectiveness of the intervention compared with usual care. Costs and benefits were discounted at 3% and expressed in 2006 Canadian dollars.
Results The intervention cost CaD $56 per patient. Compared with usual care, the intervention strategy was dominant: for every 100 patients case managed, 6 fractures (4 hip fractures) were prevented, 4 quality-adjusted life-years were gained, and CaD $260 000 was saved by the health care system. Irrespective of the number of patients case managed, the intervention reached a break-even threshold within 2 years. The intervention dominated usual care over the entire spectrum of 1-way sensitivity analyses and was cost-saving in 82% of probabilistic model simulations.
Conclusions Compared with usual care, we found that using a case manager for patients with hip fractures increased rates of appropriate osteoporosis treatment. The intervention dominated usual care, and the analysis suggests that systems implementing an intervention similar to ours should expect to see a reduction in fractures, gains in life expectancy, and substantial cost savings.
Trial Registration clinicaltrials.gov Identifier: