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#17
14.10.2005, 20:23
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Цитата:
SEE Program Electronic Edition 78. Which statement about patients who survive out-of-hospital cardiac arrest is MOST likely true? A. Survival is increased for patients treated with vasopressin for an initial rhythm of ventricular fibrillation compared to those treated with epinephrine. B. Survival is increased for patients treated with vasopressin for an initial rhythm of asystole compared to those treated with epinephrine. C. Survival is increased for patients treated with vasopressin for an initial rhythm of pulseless electrical activity compared to those treated with epinephrine. D. Survival is unchanged when vasopressin and epinephrine are used together. Comments on the incorrect answers A. No significant difference between vasopressin and epinephrine was shown in the rate of survival to hospital admission or discharge for an initial rhythm of ventricular fibrillation. C. No significant difference between vasopressin and epinephrine was shown in the rate of survival to hospital admission or discharge for an initial rhythm of pulseless electrical activity. D. Patients who initially received two doses of vasopressin followed by epinephrine for refractory cardiac arrest had a higher rate of survival to hospital admission and discharge (p < 0.002) than the epinephrine-only group. Correct answer is B In the United States alone, over 1,000 sudden cardiac deaths take place every day. A recent study compared the use of vasopressin and epinephrine for patients treated for out-of-hospital cardiac arrest. This study was a double-blind, prospective, multicenter European study and data were acquired by 44 physician-staffed emergency medical units. A total of 1,186 patients were randomized into two groups. The initial drug treatment for the out-of-hospital cardiac arrest was either vasopressin 40 IU intravenously (IV) or epinephrine 1 mg IV; both groups had similar clinical and demographic profiles. If the patient remained refractory to treatment (in cardiac arrest after receiving two doses of the study drug), epinephrine was given at the discretion of the physician. Thus one group could receive two doses of vasopressin followed by epinephrine and the other could receive three doses of epinephrine. The endpoints of the study were survival to hospital admission and to hospital discharge. Overall there was no difference in the initial rate of restoration of circulation, admission to hospital, or survival to hospital discharge between the groups receiving vasopressin and epinephrine. The study showed no significant differences in the rate of hospital admission or discharge in all patients who responded to the study drug and were diagnosed with ventricular fibrillation or pulseless electrical activity. For patients in asystole who responded to the study drug, the vasopressin group had an increased hospital admission rate (p < 0.02, odds ratio 0.6, confidence interval 0.4-0.9). Eight additional patients survived to hospital discharge in the vasopressin group (12/257) when compared to the epinephrine group (4/262). Using odds ratio analysis this did not reach significance (OR 0.3, CI 0.1-1.0). All patients who had refractory cardiac arrest (did not respond to two doses of study drug and then received a dose of epinephrine) appeared to be more likely to survive to hospital admission (OR 0.6, CI 0.4-0.8) and hospital discharge (OR 0.3, CI 0.1-0.6) when they initially received vasopressin. In patients with asystole and refractory cardiac arrest, seven of 184 patients survived to hospital discharge in the vasopressin group while zero of 179 patients in the epinephrine group survived to hospital discharge. Additional results of the study included increased survival to hospital admission with a witnessed arrest versus a nonwitnessed arrest (p < 0.001), the use of amiodarone (p < 0.001), and the administration of fibrinolysis (p = 0.01). In an editorial accompanying this study, the author suggested that the treatment strategy of combined vasopressin and epinephrine be incorporated into clinical practice without further delay based on the encouraging results of this study, the current dismal outlook for patients in asystole, and no obvious additional risks. This improved outcome, however, did not extend to hospital discharge and was based on a difference to only 8 patients of the 511 in both study groups. Likewise the improved outcome in the vasopressin group in patients with refractory cardiac arrest is based on a very small number of additional survivors (7). Also, the statistical tests did not adjust for multiple comparisons. Therefore, conclusions regarding the efficacy of vasopressin in asystole may be biased. Increased endogenous vasopressin concentrations have been found in patients who survive cardiac arrest. Vasopressin has been postulated to be an effective vasopressor while also increasing coronary perfusion. Conversely, epinephrine could be detrimental in cardiac arrest secondary to increased myocardial oxygen consumption, new onset of dysrhythmias, and the development of myocardial dysfunction. It is possible that vasopressin and epinephrine may act synergistically, especially when asystole or refractory cardiac arrest occurs. Current Advanced Cardiac Life Support guidelines recommend either vasopressin or epinephrine as the initial pharmacological treatment of cardiac arrest. REFERENCES Wenzel V, Krismer AC, Arntz HR, et al. A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med. 2004; 350:105-113. McIntyre KM. Vasopressin in asystolic cardiac arrest. N Engl J Med. 2004; 350:179-181. Miller RD, Cucchiara RF, Miller ED, Jr. et al. Anesthesia. 5th ed. Philadelphia: Churchill Livingstone; 2000:2545-2548. 
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#18
16.10.2005, 00:14
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Цитата:
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#19
16.10.2005, 17:44
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Результаты не очень впечатляют.Мы не использовали вазопрессин в своей клинике по причине его отсутствия.В целом,асистолия сердца и эл.мех. диссоциация очень редко бывают первичными.При асистолии сердца я могу вспомнить 2-3 успешные реанимации,да и то,когда причиной асистолии стала далеко зашедшая АВ-блокада.Тогда помогла трансторакальная стимуляция сердца.Методика,надо заметить,не очень эстетичная,но время выиграли и жизнь спасли.
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