Department of Cardiology, Rigshospitalet - Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, OE, Denmark.
Department of Thoracic Anesthesiology, Rigshospitalet - Copenhagen University Hospital, Copenhagen, Denmark.
Crit Care. 2024 Jan 22;28(1):28. doi: 10.1186/s13054-024-04808-3.
Following resuscitated out-of-hospital cardiac arrest (OHCA), inflammatory markers are significantly elevated and associated with hemodynamic instability and organ dysfunction. Vasopressor support is recommended to maintain a mean arterial pressure (MAP) above 65 mmHg. Glucocorticoids have anti-inflammatory effects and may lower the need for vasopressors. This study aimed to assess the hemodynamic effects of prehospital high-dose glucocorticoid treatment in resuscitated comatose OHCA patients.
The STEROHCA trial was a randomized, placebo-controlled, phase 2 trial comparing one prehospital injection of methylprednisolone 250 mg with placebo immediately after resuscitated OHCA. In this sub-study, we included patients who remained comatose at admission and survived until intensive care unit (ICU) admission. The primary outcome was cumulated norepinephrine use from ICU admission until 48 h reported as mcg/kg/min. Secondary outcomes included hemodynamic status characterized by MAP, heart rate, vasoactive-inotropic score (VIS), and the VIS/MAP-ratio as well as cardiac function assessed by pulmonary artery catheter measurements. Linear mixed-model analyses were performed to evaluate mean differences between treatment groups at all follow-up times.
A total of 114 comatose OHCA patients were included (glucocorticoid: n = 56, placebo: n = 58) in the sub-study. There were no differences in outcomes at ICU admission. From the time of ICU admission up to 48 h post-admission, patients in the glucocorticoid group cumulated a lower norepinephrine use (mean difference - 0.04 mcg/kg/min, 95% CI - 0.07 to - 0.01, p = 0.02). Moreover, after 12-24 h post-admission, the glucocorticoid group demonstrated a higher MAP with mean differences ranging from 6 to 7 mmHg (95% CIs from 1 to 12), a lower VIS (mean differences from - 4.2 to - 3.8, 95% CIs from - 8.1 to 0.3), and a lower VIS/MAP ratio (mean differences from - 0.10 to - 0.07, 95% CIs from - 0.16 to - 0.01), while there were no major differences in heart rate (mean differences from - 4 to - 3, 95% CIs from - 11 to 3). These treatment differences between groups were also present 30-48 h post-admission but to a smaller extent and with increased statistical uncertainty. No differences were found in pulmonary artery catheter measurements between groups.
Prehospital treatment with high-dose glucocorticoid was associated with reduced norepinephrine use in resuscitated OHCA patients.
EudraCT number: 2020-000855-11; submitted March 30, 2020. URL: https://www.
gov ; Unique Identifier: NCT04624776.
在复苏后的院外心搏骤停（OHCA）后，炎症标志物显著升高，并与血流动力学不稳定和器官功能障碍相关。推荐使用血管加压药支持以维持平均动脉压（MAP）高于 65mmHg。糖皮质激素具有抗炎作用，可能降低对血管加压药的需求。本研究旨在评估院前大剂量糖皮质激素治疗复苏后昏迷 OHCA 患者的血流动力学效应。
STEROHCA 试验是一项随机、安慰剂对照、2 期试验，比较了复苏后 OHCA 患者立即给予单剂量甲泼尼龙 250mg 与安慰剂。在这项子研究中，我们纳入了入院时仍昏迷并存活至 ICU 入院的患者。主要结局是 ICU 入院至 48 小时累积去甲肾上腺素用量，以 mcg/kg/min 表示。次要结局包括 MAP、心率、血管活性-正性肌力评分（VIS）和 VIS/MAP 比值以及肺动脉导管测量评估的心脏功能等血流动力学状态。采用线性混合模型分析评估两组在所有随访时间的平均差异。
共纳入 114 例昏迷 OHCA 患者（糖皮质激素组：n=56，安慰剂组：n=58）进行子研究。两组在 ICU 入院时的结局无差异。从 ICU 入院到入院后 48 小时，糖皮质激素组累积去甲肾上腺素用量较低（平均差异-0.04 mcg/kg/min，95%CI-0.07 至-0.01，p=0.02）。此外，入院后 12-24 小时，糖皮质激素组 MAP 更高，平均差异为 6-7mmHg（95%CI 1-12），VIS 更低（平均差异-4.2 至-3.8，95%CI-8.1 至 0.3），VIS/MAP 比值更低（平均差异-0.10 至-0.07，95%CI-0.16 至-0.01），而心率无明显差异（平均差异-4 至-3，95%CI-11 至 3）。这些组间治疗差异在入院后 30-48 小时也存在，但程度较小，且具有更高的统计不确定性。两组之间的肺动脉导管测量值无差异。
院前使用大剂量糖皮质激素治疗复苏后的 OHCA 患者与去甲肾上腺素用量减少相关。
EudraCT 编号：2020-000855-11；提交日期：2020 年 3 月 30 日。网址：https://www.clinicaltrials.gov；独特标识符：NCT04624776。
