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ACLS and Vasopressin

 

ACLS and Vasopressin

Vasopressin is a primary drug used in the pulseless arrest algorithm. In high concentrations, it raises blood pressure by inducing moderate vasoconstriction, and it has been shown to be more effective than epinephrine in asystolic cardiac arrest (Wenzel V, Krismer AC, Arntz HR, Sitter H, Stadlbauer KH, Lindner KH (January 2004). “A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation”. N. Engl. J. Med. 350 (2): 105–13. doi:10.1056/NEJMoa025431. PMID 14711909.)

One major indication for vasopressin over epinephrine is its lower risk for adverse side effects when compared with epinephrine. With epinephrine, some studies have shown a risk of increased myocardial oxygen consumption and post arrest arrhythmias because of an increase in heart rate and contractility (beta 1 effects). Vasopressin also is thought to cause cerebral vessel dilation and theoretically increase cerebral perfusion.

Trivia: Another name for vasopressin is antidiuretic hormone (ADH).

Routes

Vasopressin may be given IV/IO or by endotracheal tube.

Dosing

40 units of vasopressin IV/IO push may be given to replace the first or second dose of epinephrine, and at this time, there is insufficient evidence for recommendation of a specific dose per the endotracheal tube.
In the ACLS pulseless arrest algorithm, vasopressin may replace the first or second dose of epinephrine.

Return to main ACLS Pharmacology page.

  76 Responses to “ACLS and Vasopressin”

  1. Other than the half life, is there some kind of physiologic contraindication to giving vasopressin?
    For example, in a long code lasting greater than 20 mins, can you theoretically give vasopressin again? Thx

  2. When giving vasopressin via et tube, should 40mg or 80mg be given? I know medications that can be given this way are usually 2-2.5 times the iv dose but I can’t find any specific recommendations for it and our crash carts only have a total of 40mg.

    Thanks

    • According to the literature, there is insufficient evidence for recommendation of a specific dose of vasopressin per the endotracheal tube.
      I would just use the 40 units in your situation.
      Kind regards,
      Jeff

    • According to the literature, there is insufficient evidence for recommendation of a specific dose of vasopressin per the endotracheal tube.
      I would just use the 40 units in your situation.

      Kind regards,
      Jeff

  3. If vasopressin is given during a VT?VF arrest, then the patient later develops PEA, can you give vasopressin again right away? Or 20 minutes after the 1st?

    • You would only want to give the vasopressin just one time. After the one dose of vasopressin you would administer epinephrine. The half-life of vasopressin is around 20 minutes.

      Kind regards,
      Jeff

  4. When substituting vasopressin for epinephrine do you have to wait 10 minutes before the next epinephrine ?

    • No. You can wait 3-5 minutes and then give the epinephrine. Since the vasopressin is only given 1 time, you can stick with the 3-5 minute rule and continue on with epinephrine.

      Kind regards,
      Jeff

  5. Can we push vasopressin dierect, without any dilution?

  6. The bottled pictured is IM or SC only not IV so cannot be given IV pitressin is IV form? Or do you give IV the IM formula? Labeling issue or should be made clearer that get inj for IV for crash carts.

  7. The ACLS video said regardless of which vasopressin you use, the dose should be given every 3-5 minutes. Is this for vasopressin also? Or do you give vasopressin every 20 minutes?
    Thanks.

    • The vasopressin is a one-time dose used to replace the first or second dose of epinephrine. After given, it IS NOT given again and epinephrine is resumed every 3-5 minutes.

      Kind regards,
      Jeff

  8. i know vasopressin can be used in pulseless v.fib/v.tach, can it also be used in asystole/PEA

  9. I’ve checked 3 sources and none say how fast to push vasopressin. Can you help?

    • Vasopressin, as with all other drugs used in the pulseless arrest algorithm, is pushed as fast as possible. After giving the medication, it is followed with a 20ml flush that is given as fast as possible. Your desire should be that the medication is pushed into the central circulation as fast as possible.

      Kind regards,
      Jeff

  10. Why can vasopressin only replace the first or second dose of epinephrine during resuscitation? I know that you only need to use it once but can it be used later on, such as after 2 doses of epinephrine? Is there evidence to explain why it can ONLY be used to replace the first or second dose?

    • Vasopressin is recommended to be given in replace of the first or second dose of epinephrine because the duration of time that it may take for vasopressin to have peak effect is considerably higher than epinephrine. The half-life of vasopressin is 10-20 minutes compared to epinephrine at 3-5 minutes. It is prudent therefore to give the vasopressin earlier in the dosing schedule.

      Kind regards,
      Jeff

  11. Is there any harm in giving EPI before or concurrent with the two rounds of defibrillation? I read your answer on why it isn’t recommended before the two defibrillations, but I’m still confused as to why it can’t be given with the shocks.
    Thank you!

    • In my experiences, I have seen epinephrine given as soon as possible if it does not delay chest compressions or defibrillation.
      However, since there is no clinical evidence that epinephrine or vasopressin improve survival to hospital discharge, it should not be emphasized in any way over chest compressions and defibrillation.

      Kind regards,
      Jeff

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