The Case

A 54-year-old man is admitted to the observation unit to rule out an acute coronary syndrome. While waiting for further testing, he has a cardiac arrest, and a code blue is called. CPR and advanced cardiac life support protocols are initiated. The resident asks if we should be administering corticosteroids because of an old trial she remembers reading.

Clinical Question

Is there better survival with a good neurological outcome in patients with cardiac arrest who are treated with corticosteroids?

Background

There are high morbidity and mortality rates with both in-hospital cardiac arrests (IHCAs) and out-of-hospital cardiac arrests (OHCAs). Improving outcomes for patients with cardiac arrest has been challenging. Various treatment modalities, such as therapeutic hypothermia, intravenous versus intraosseous access, supraglottic airways, crowdsourcing CPR, and mechanical CPR, have been tried with mixed results.^1–6

A randomized controlled trial (RCT) published in 2013 investigated a protocol of vasopressin, steroids, and epinephrine (VSE) for IHCAs.⁷ It reported a better odds ratio for return of spontaneous circulation (ROSC) and survival to discharge, with good neurological outcome with the protocol. This was an interesting finding, but a validation study replicating the results has apparently not been published.

An older RCT looked at the role of the corticosteroid dexamethasone in OHCA.⁸ That trial failed to demonstrate improvement in survival to hospital discharge. Liu et al performed a systematic review and meta-analysis on the use of corticosteroids after cardiac arrest.⁹ They found there was an increase in ROSC and survival to discharge but were limited by the availability of adequately powered high-quality RCTs.

Reference: Shah K, Mitra AR. Use of corticosteroids in cardiac arrest-a systematic review and meta-analysis. Crit Care Med. 2021;49(6):e642-e650.

• Population: RCTs and observational studies of patients with IHCA or OHCA
  • Exclusions: Single-arm studies, case reports/series, narrative reviews, and studies irrelevant to the focus of this article
• Intervention: Corticosteroids as adjunct therapy in cardiac arrest
• Comparison: Patients who did not receive corticosteroids in cardiac arrest
• Outcomes:
  • Primary Outcomes: Good neurological outcome (measured using the Glasgow-Pittsburgh Cerebral Performance Category score), survival to hospital discharge, and survival at equal to or greater than one year
  • Secondary Outcomes: ROSC, ICU and hospital length of stay (LOS), duration of vasopressor and inotropic treatment, and blood pressure including mean arterial pressure during CPR and after ROSC

Authors’ Conclusions

“Our study found that there are limited high-quality data to analyze the association between corticosteroids and reducing mortality in cardiac arrest, but the available data do support future randomized controlled trials. We did find that corticosteroids given as part of a vasopressin, steroids, and epinephrine regimen in in-hospital cardiac arrest patients and for postresuscitation shock did improve neurologic outcomes, survival to hospital discharge, and surrogate outcomes that include return of spontaneous circulation and hemodynamics. We found no benefit in in-hospital cardiac arrest or out-of-hospital cardiac arrest patients receiving corticosteroids only; however, a difference cannot be ruled out due to imprecision and lack of available data.”