UMEM Educational Pearls

Category: Critical Care

Title: Adding Vasopressin and Steroids to the Code Cocktail? Not so fast...

Keywords: in-hospital cardiac arrest, IHCA, resuscitation, code, epinephrine, vasopressin, methylprednisolone (PubMed Search)

Posted: 5/2/2022 by Kami Windsor, MD (Emailed: 5/3/2022)
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Based on prior studies1 indicating possibly improved outcomes with vasopressin and steroids in IHCA (Vasopressin, Steroids, and Epi, Oh my! A new cocktail for cardiac arrest?), the VAM-IHCA trial2 compared the addition of both methylprednisolone and vasopressin to normal saline placebo, given with standard epinephrine resuscitation during in hospital cardiac arrest (IHCA).

The use of methylprednisolone plus vasopressin was associated with increased likelihood of ROSC: 42% intervention vs. 33% placebo, RR 1.3 (95% CI 1.03-1.63), risk difference 9.6% (95% CI 1.1-18.0%); p=0.03.

BUT there was no increased likelihood of favorable neurologic outcome (7.6% in both groups).

Recent publication on evaluation of long-term outcomes of the VAM-ICHA trial3 showed that, at 6-month and 1-year follow-up, there was no difference between groups in:

  • Survival
  • Favorable neurologic outcome (CPC 1 or 2; mRS 0-3)
  • Health-related quality of life (per EQ-5D5L survey)


Bottom Line: Existing evidence does not currently support the use of methylprednisolone and vasopressin as routine code drugs for IHCA resuscitation. 


Basic study characteristics:

  • Multicenter, double-blind, placebo-controlled RCT in 10 Denmark hospitals
  • 501 adult patients with IHCA receiving at least 1 dose of epinephrine
  • Intervention: 40mg methylprednisolone + 20 IU vasopressin given ASAP after 1st dose of Epi (additional vasopressin given with epinephrine for up to 4 doses)
  • 64% men, mean age 71yrs, 74% witnessed IHCA, 90% initial nonshockable rhythms

Some of the limitations:

  • High exclusion rate (1850 patients out of 2362 screened)
  • Non-consecutive enrollment
  • Not powered for survival with good neurologic outcomes
  • Post-ROSC, more of placebo group got steroids than the intervention group (46% vs 24%) 
  • More ECMO in the placebo group (30% vs 14%)