So I’ve been asked a few times for my opinion about the VSE study in the last couple of months, so here we go.
JAMA. 2013;310(3):270-279. doi:10.1001/jama.2013.7832.
First of all, lets look at it from a theoretical perspective. How would steroids contribute to ROSC (return of spontaneous circulation)? Hard to believe they possibly could, given the ultra-short timeframe to ROSC – minutes mostly – and the much longer action of steroids. However, it is quite possible – and in view of this study perhaps likely – that there is an effect on shock and RONF (return of neurological function).
Why? Post arrest shock results in MSOF due to a cascade of inflammation resulting from the hypoxic insult. Remember that we are not designed to survive these events. Being designed to fight off moderate trauma and infection (eg being bitten by an animal or clubbed by another caveman) our physiological reaction often overshoots the mark resulting in more damage than good, as it does in sepsis (variably depending on our different geno/phenotypes). So whether liver, kidney or brain damage, some component is not only related to pure hypoxia but also to an inflammatory cascade that has a prolonged effect. This is the same thing we are targeting with cooling, on top of a simple metabolic supply/demand issue, so in terms of biological plausibility, it makes some sense.
In the post-ROSC phase, there is always the possibility of relative adrenal insufficiency – after all, the adrenals have taken a hit as all the other organs did – so again there is biological plausibility.
There’s quite a bit of debate out there as to whether or not to apply this. I’m pragmatic, not a purist, and my beliefs lie in evidence, biological plausibility and the risk/benefit ratio. In this case, I think the decision is actually quite simple. The way I see it, the steroids are harmless and probably helpful, so I have been giving solumedrol in the last few months.
If anything, I’m more concerned about the harm I may be doing with epinephrine/vasopressin, especially in terms of RONF. I do hope an epi (various doses) vs placebo study is done, because it is difficult to withhold, knowing that there is greater immediate effect on ROSC… Hard decision as the clinician at the bedside, and hopefully this will become clearer in the near future.
For those unclear about the whole epi debate, the physiological issue is that the relationship between pressure and perfusion is represented by an inverted U curve – at very high pressures (from vasoconstriction) perfusion is decreased (think of the extremities on high dose pressers with a decent BP). So although we may help coronary perfusion pressure and thus ROSC, end-organ damage is greater…and nothing matters much without a brain.
So bottom line: I’d go ahead with the steroids, and for now the V and E, but I wouldn’t be surprised to drop or decrease those soon.
More to come on resuscitation and its future (the present for some of us…) in posts and podcasts!
Hope this helps!