Vasopressin and steroids in addition to adrenaline in cardiac arrest (VAST-A) – A randomised pilot study

Abstract

Background

The potential benefit of combining adrenaline, vasopressin, and corticosteroids in in-hospital cardiac arrest (IHCA) needs to be confirmed in a large clinical trial. This pilot study assesses feasibility and safety of randomising patients to this combination therapy compared to standard care.

Material and methods

A randomised, double-blind, placebo-controlled pilot study was conducted from December 2022 to June 2024 across three Swedish hospitals (NCT05139849). Witnessed IHCAs meeting criteria for adrenaline were randomised 1:1 to adrenaline, vasopressin, and corticosteroids (intervention) or adrenaline and placebo (control). Primary outcomes included feasibility (e.g., protocol adherence, event times, enrolment rate), and safety. Secondary outcome was return of spontaneous circulation.

Results

Of 183 screened IHCAs, 39 patients (median age 77, 64% male) were randomised (16 intervention, 23 control), with an enrolment rate of 0.8 patients/hospital bed/month. Most cardiac arrests occurred in general wards (n = 17/39, 44%). In the feasibility analysis, four patients at the scene of the arrest and three patients in the intensive care unit experienced protocol deviations. Median time (minutes) from cardiac arrest to rapid response team arrival was similar between groups. Median time to adrenaline administration was 7:00 (IQR 3:00–10:00) (intervention) vs 5:00 (IQR 2:30–8:30) (control) and to vasopressin/placebo 10:30 (IQR 9:30–12:15) vs 9:00 (IQR 5:00–11:00). Return of spontaneous circulation occurred in 38% (6/16) in the intervention group and 17% (4/23) in controls.

Conclusion

In this IHCA pilot study, randomisation to adrenaline, vasopressin, and corticosteroids compared to controls was safe, but feasibility needs improvement for adequate enrolment in the VAST-A main study.