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Steroids for Cardiac Arrest

Question Type:
Intervention
Full Question:
Among adults who are in cardiac arrest in any setting (P), does does corticosteroid or mineralocorticoid administration during CPR  (I), compared with compared with not using steroids  (C), change Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC (O)?
Consensus on Science:
In-Hospital Cardiac Arrest

For the critical outcome of survival to discharge with favorable neurologic outcome, there was low-quality evidence (downgraded for indirectness and for imprecision) from 1 RCT(Mentzelopoulos 2013, 270) in 268 patients with IHCA that showed improved outcome with methylprednisolone, vasopressin, and epinephrine during cardiac arrest, and hydrocortisone in those with post-ROSC shock compared with only epinephrine and placebo (18/130 [13.9%] versus 7/138 [5.1%]; RR, 2.94; 95% CI, 1.16–6.50, which translates to 98 more/1000 surviving with good neurologic outcome [95% CI, from 8–279 more/1000 surviving with good neurologic outcome]).

For the critical outcome of survival to discharge, there was low-quality evidence (downgraded for indirectness and for imprecision) from 1 RCT(Mentzelopoulos 2009, 15) of 100 patients with IHCA that showed improved outcome with the combination of methylprednisolone, vasopressin, and epinephrine during cardiac arrest and hydrocortisone after ROSC for those with shock, compared with the use of only epinephrine and placebo (9/48 [19%] versus 2/52 [4%]; RR, 4.87; 95% CI, 1.17–13.79, which translates to 149 more/1000 surviving to discharge [95% CI, 7–492 more/1000 surviving to discharge]).

For the important outcome of ROSC, there was low-quality evidence (downgraded for indirectness and imprecision) from 2 RCTs(Mentzelopoulos 2009, 15; Mentzelopoulos 2013, 270) involving 368 patients with IHCA showing improved outcome with the use of methylprednisolone and vasopressin in addition to epinephrine, compared with the use of placebo and epinephrine alone (combined RR, 1.34; 95% CI, 1.21–1.43, which translates to 130–267 more achieving ROSC with the combination of methylprednisolone, vasopressin, and epinephrine during cardiac arrest, compared with the use of only epinephrine and placebo [95% CI, 130–267 more achieving ROSC]).

Out-of-Hospital Cardiac Arrest

For the critical outcome of survival to discharge, there was very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 RCT and 1 observational study(Paris 1984, 1008; Tsai 2007, 318) showing no association with benefit with the use of steroids. Paris had no long-term survivors and Tsai showed survival to discharge in 8% (3/36) receiving hydrocortisone compared with 10% (6/61) receiving placebo (P=0.805).

For the important outcome of ROSC, we found very-low-quality evidence from 1 RCT(Paris 1984, 1008) and 1 observational study(Tsai 2007, 318) with a combined total of 183 patients. The RCT(Paris 1984, 1008) showed no improvement in ROSC (and ICU admission) with dexamethasone given during cardiac arrest compared with placebo (5.4% [2/37] versus 8.7% [4/46]), but the observational study(Tsai 2007, 318) showed an association with improved ROSC with hydrocortisone compared with no hydrocortisone (58% versus 38%; P=0.049).
Treatment Recommendation:
For IHCA, the task force was unable to reach a consensus recommendation for or against the use of steroids in cardiac arrest.

We suggest against the routine use of steroids during CPR for OHCA (weak recommendation, very-low-quality evidence).

Values, Preferences, and Task Force Insights

In making this recommendation for IHCA, it was noted that there were no studies assessing the effect of the addition of steroids alone to standard treatment for IHCA. Also, although the triple-agent drug regimen appears to suggest an association with improved outcome, the population studied had very rapid ALS, a high incidence of asystolic cardiac arrest, and low baseline survival compared with other IHCA studies, so some of the observed effects might be peculiar to the population studied.

In making this recommendation for OHCA, we considered the cost and distraction from the addition of treatments for which there is very low confidence in any effect. The different recommendation for OHCA and IHCA was influenced by the physiological differences between these conditions, such as the incidence of sepsis, adrenal insufficiency from critical illness, and cardiovascular etiologies.
CoSTR Attachments:
AMSTARguidelineTool.pdf    
Characteristics of the 2 Studies by Mentzelopoulos 2009+ 13 for AMSTAR.doc    
Final Article selection for Steroids in CA.xls    
GradePro table for Steroids during CPR for IHCA.doc    
GradePro table for Steroids during CPR for OHCA.doc    
Observational Studies on smoking in pregnanch; GradePro.doc    
RR Forest plot.svg    
Summary of Bias Assessments for Use of Steroids in Cardiac Arrest.xls    

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