'Roids to the Rescue?
/Obling LER, Beske RP, Meyer MAS, et al. Effect of prehospital high-dose glucocorticoid on hemodynamics in patients resuscitated from out-of-hospital cardiac arrest: a sub-study of the STEROHCA trial. Crit Care 2024;28(1):28. 10.1186/s13054-024-04808-3
This was a post-hoc analysis of a placebo-controlled randomized control trial comparing high-dose methylprednisolone versus placebo in out of hospital cardiac arrest (OHCA). In this study, the authors aim to assess the hemodynamic effects of prehospital high-dose glucocorticoid treatment in resuscitated comatose OHCA patients. The parent trial was conducted from October 2020 to July 2022 in the capital region of Denmark. The trial included patients with OHCA of presumed cardiac cause who were unconscious on prehospital randomization, had sustained ROSC for at least 5 minutes, and initiation of treatment within 30 minutes of sustained ROSC. Patients were excluded if they were less than 18 years old, had termination of resuscitation, had asystole as their primary rhythm, were women of childbearing potential, had a known allergy to glucocorticoids, had a high prearrest modified Rankin scale (mRS), temperature upon randomization less than 30 C, or greater than 30 minutes to sustained ROSC. A random number generator was used to determine if the patient received placebo or study drug, methylprednisolone 250 mg given IV or IO. Prehospital personnel were blinded until they opened an opaque container at which time they were unblinded to drug vs placebo. The intervention was given in all cases prior to arrival at one of two cardiac arrest centers. All further medical personnel involved in the patient's care remained blinded. All patients then received standard of care for that facility.
There were 114 patients included in the final analysis. The primary outcome was cumulative norepinephrine use during the first 48 hours of admission. Secondary outcomes included mean arterial pressure (MAP), heart rate, vasoactive inotropic score (VIS) – a weighted score of different cardiovascular active agents, VIS/MAP, and pulmonary artery catheter (PAC) monitoring. Around half of the patients went to a center where PAC monitoring was standard of care in cardiac arrest patients. For the most part, there was no significant difference in patient characteristics between groups. Interestingly, the only significant differences were in those patients who received steroid having longer average time to ROSC, more doses of epinephrine given, and more patients in this group receiving amiodarone. Authors hypothesized that this difference was due to the small sample size.
In this post-hoc analysis, the authors found that patients who had received methylprednisolone had statistically significant higher MAP throughout the first 48 hours of their hospital stay, received lower doses of norepinephrine at 12 and 24 hours, and had lower VIS at 24 hours and 48 hours. They did not find any differences in heart rate and there were no differences in PAC hemodynamic monitoring. While there were no statistically significant differences in mortality or mRS between groups, there did appear to be a signal towards benefit in the methylprednisolone group.
Overall, this study is limited by its post-hoc analysis and the fact that it was not part of the original hypothesis of the parent study. It has a small sample size and may not be generalizable as it was carried out in Denmark where physicians were present on all transport vehicles and there is a very high portion of the population trained in providing bystander CPR. That said, outcomes for these patients are generally poor and the use of steroids as a one-time dose likely has little risk. As far as adverse events, the only significant adverse events statistically were metabolic and endocrine derangements as would be expected in patients receiving glucocorticoids. There was no statistically significant difference in serious adverse events between groups. As the authors stated, this is a hypothesis generating study but does show promise as a possible low risk intervention that may contribute to improving outcomes in a population that we encounter regularly in the emergency department but traditionally does not fare well.
Authorship
Written by/Audio by: Dave Jackson, PGY-3, University of Cincinnati Department of Emergency Medicine
Editing/Posting/Video Editing: Jeffery Hill, MD MEd Associate Professor, University of Cincinnati Department of Emergency Medicine
Cite As: Jackson, D., Hill, J. 'Roids to the Rescue? TamingtheSRU. www.tamingthesru.com/blog/journalclub/sterohca. 3/27/2024.
