At this month’s PTM Journal Club, we explored the use of high-dose glucocorticoid on hemodynamics in the prehospital setting; in particular, the STEROHCA trial conducted in Denmark.
Effect of prehospital high-dose glucocorticoid on hemodynamics in patients resuscitated from out-of-hospital cardiac arrest: a sub-study of the STEROHCA trial
Background and Objectives
Out-of-hospital cardiac arrest (OHCA) carries significant morbidity and mortality risks. Following successful resuscitation, patients face a heightened likelihood of developing post-resuscitation shock and multiorgan failure. Myocardial dysfunction and reperfusion injury, accompanied by systemic inflammation, play a significant role in the patient’s clinical deterioration during the initial days post-admission. While vasopressors are used to maintain adequate tissue perfusion, excessive use correlates with unfavourable outcomes. Glucocorticoids have shown potential in reducing vasopressor dependency among shock patients, yet their impact on post-cardiac arrest individuals remains less explored. The STEROHCA sub-study seeks to evaluate the effects of early anti-inflammatory treatment with high-dose glucocorticoids on hemodynamics and vasopressor utilization during the post-resuscitation phase following OHCA.
Methods
The parent STEROCHA trial was conducted in Denmark in 2013 by Obling et al., who aimed to investigate the anti-inflammatory and neuroprotective effects and the survival rates associated with prehospital administration of high-dose glucocorticoids following OHCA.
This study was a randomized, placebo-controlled, phase 2 trial that compared one prehospital dose of methylprednisolone (250mg) versus placebo immediately after resuscitated OHCA. This sub-study sought to evaluate the hemodynamic impacts of high-dose glucocorticoids post-cardiac arrest and included 114 patients who were in a coma and admitted to the ICU.
The patients were randomized (1:1 ratio) in permuted blocks of four.
The primary outcome was the cumulative use of norepinephrine from ICU admission until 48 hours post-resuscitation.
Secondary outcomes included hemodynamic parameters such as heart rate, mean arterial pressure (MAP), vasoactive-inotropic score (VIS), which is calculated by all vasoactive and inotropic medications administered, and the VIS/MAP ratio, which quantifies the relationship between vasopressor and inotropic support provided. Additional secondary outcomes included cardiac function assessed through pulmonary artery catheter measurements.
Authors’ Conclusions
Prehospital treatment with methylprednisolone (250mg) was associated with reduced norepinephrine use in resuscitated OHCA patients.
Limitations
This sub-analysis was post hoc and not initially hypothesized in the parent STEROCHA study. The trial included only 114 patients and may lack generalizability, given that it was conducted in Denmark, where physicians were available on all transport vehicles and a high proportion of their bystanders are trained in CPR. While endocrinological disturbances are anticipated with glucocorticoid administration, there were no other statistically significant difference in adverse events observed between the groups.
Bottom Line
Although this was a hypothesis-generating study, this low-risk intervention may improve outcomes in patients with low baseline survival rates. Further prospective studies are needed before advocating for its use within the prehospital setting.
Full Citation
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. Published 2024 Jan 22. doi:10.1186/s13054-024-04808-3
If you missed our last Journal Club Recap, click HERE to read more.
