Study Revolutionizes IHCA Management: The Promise of Triple Therapy with Adrenaline, Vasopressin, and Corticosteroids

A recent pilot study called "Vasopressin and steroids in addition to adrenaline in cardiac arrest (VAST-A)" aimed to assess the feasibility and safety of administering a combination therapy involving adrenaline, vasopressin, and corticosteroids in in-hospital cardiac arrest (IHCA) patients compared to standard care. The study ran from December 2022 to June 2024 across three Swedish hospitals and enrolled 39 patients (median age 77, 64% male) out of 183 screened IHCA cases. The primary outcomes focused on feasibility, protocol adherence, safety, and return of spontaneous circulation (ROSC).

Research Background

Previous research suggested benefits of combining vasopressin and corticosteroids with adrenaline in cardiac arrest, showing improved ROSC and survival rates. The study prepared for a larger investigation aiming to evaluate the effect of this combination on 30-day survival in IHCA patients. The pilot study highlighted challenges in randomization and drug administration timing, with protocol deviations occurring at the scene and in the ICU, indicating the need for protocol adjustments. While no major adverse events were reported, there was a tendency for delays in drug administration in the intervention group, emphasizing the importance of timely interventions during cardiopulmonary resuscitation (CPR).

Safety Analysis

The safety analysis revealed no premature administration of study drugs before adrenaline. Protocol deviations were seen in 10% of cases, particularly in the ICU, impacting study drug administration post-arrest. The median time to adrenaline was 7:00 minutes in the intervention group and 5:00 minutes in the standard care group, with similar trends observed for study drug administration. The rate of ROSC was 38% in the intervention group and 17% in the standard care group, although statistical significance was not reached.

Study Limitations

The pilot study identified limitations such as a lower-than-expected enrollment rate, protocol deviations, and the need for streamlined drug administration processes. These findings underline the importance of optimizing the study protocol before launching the main VAST-A study nationwide in 2025. Adjustments in randomization procedures, drug preparation, and administration are crucial to enhance the feasibility and safety of administering a combination regimen in IHCA patients. In conclusion, the pilot study demonstrated the safety of the proposed combination therapy and highlighted the necessity of refining protocols for improved patient recruitment and streamlined drug delivery in preparation for the larger VAST-A main study. This comprehensive assessment laid the groundwork for future investigations into the efficacy of combining vasopressin and corticosteroids with adrenaline in IHCA scenarios.

Key Points

- The pilot study named "Vasopressin and steroids in addition to adrenaline in cardiac arrest (VAST-A)" aimed to evaluate the feasibility and safety of administering a combined therapy involving adrenaline, vasopressin, and corticosteroids in in-hospital cardiac arrest (IHCA) patients, compared to standard care. It took place across three Swedish hospitals from December 2022 to June 2024 and included 39 patients with a median age of 77, of which 64% were male.

- Previous research indicated potential benefits of combining vasopressin and corticosteroids with adrenaline in cardiac arrest, leading to improved return of spontaneous circulation (ROSC) and survival rates, which set the stage for a larger investigation into the impact of this combination on 30-day survival in IHCA patients.

- The safety analysis of the pilot study revealed no instances of premature administration of study drugs before adrenaline, although protocol deviations were observed in 10% of cases, particularly affecting drug administration post-arrest in the ICU. The median time to adrenaline was 7 minutes in the intervention group and 5 minutes in the standard care group, with similar trends noticed for study drug administration. The rate of ROSC was 38% in the intervention group and 17% in the standard care group, although statistical significance was not achieved.

- Limitations of the pilot study included a lower-than-expected enrollment rate, protocol deviations, and the necessity for optimized drug administration processes. These identified shortcomings emphasize the crucial need for refinements in randomization procedures, drug preparation, and administration for enhanced feasibility and safety before launching the main VAST-A study nationwide in 2025.

- The pilot study established the safety of the proposed combined therapy and underscored the importance of protocol enhancements to facilitate improved patient recruitment and efficient drug delivery for the upcoming larger VAST-A main study. This preliminary assessment serves as a foundation for future research investigating the efficacy of combining vasopressin and corticosteroids with adrenaline in IHCA scenarios.

Reference –

Malin Albert et al. (2025). Vasopressin And Steroids In Addition To Adrenaline In Cardiac Arrest (VAST-A) - A Randomised Pilot Study.. *Resuscitation*, 110593 . https://doi.org/10.1016/j.resuscitation.2025.110593.