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.

Comments

  1. john says

    I always hear that the doctor want higher dose of epi, can you double the dose to give instead of just 1 mf epi IVP? thanks

    • says

      This would be incorrect. American Heart Association gives no recommendation for the use of any more than 1 mg of epinephrine per dose. There is no indication for giving more than 1 mg of epinephrine per dose and I don’t think I have ever seen any research that shows any added benefit for more than 1 mg per dose.

      Kind regards,

      Jeff

  2. Dary Boyd says

    Jeff,

    Can you point me in the right direction, for the literature on giving Epi. 3-5 mins after Vasopressin: in saying you gave Vasopressin to replace the first round of Epi. I have found it to be unclear to many, the way it is written and many think that once you have given Vasopressin you’re done for 20mins (this being the half-life).

    Thank you
    Dary

    • says

      Any of the American Heart Association literature makes this clear. Vasopressin is used as a replacement for the first or second dose of epinephrine and then epinephrine continues every 3 to 5 minutes. Vasopressin is only given once. Epinephrine can be given an unlimited number of times every 3 to 5 minutes. This is spelled out clearly in all of the American Heart Association ACLS education material.
      I’m not sure how I can make it more clear, but just realize that vasopressin simply replaces the first or second dose of epinephrine.

      Kind regards,

      Jeff

      • says

        Don’t count on not having refrigerated vasopressin. We are removing vasopressin out of the crash cart r/t the refrigerator issue. ICU/CCU may have in their frigs, however that is a trial because who has the time to run to the refrigerator in those first few minutes of the arrest. Prove that vasopressin actually does make a difference over epinephrine, maybe things will be different. However I see it given as that last ditch effort, which you only have the 1st or 2nd dose to decide that.

    • says

      Magnesium sulfate would be given only in the case of torsades de pointes which is a type of polymorphic VT that is commonly seen when magnesium levels are low. Otherwise, the only four medications that are given for VF and pulseless VT are epinephrine, vasopressin, amiodarone and/or lidocaine.

      Kind regards,
      Jeff

  3. says

    do you give 2 shocks before you give your first dose of epi
    check rhythm (shockable) clear then shock, resume cpr for 2min, check rhythm if shockable-clear then shock then give first dose of epi ??

      • says

        Really? I have been a TSF for a decade and we teach that in real time, it is likely that you will have performed the first defib and CPR cycle before you are ready to administer any IV/IO/Airway meds, but that if you have IV access at the time of the VF event, you can give the first epi before the second shock. Amiodarone, though, will always be after the second shock because per AHA, “consider anti-arrhythmics for refractory VF”.
        R/ paul cauchon

      • says

        In real scenarios, providers are at liberty to divert from the algorithm. I agree that many times in real scenarios epinephrine is given as soon as IV access is available and there is a person available that can push medications.

        Kind regards,
        Jeff

  4. dotyta1 says

    If the vasopressin has a lower risk of side effects then why would they not make it the drug of choice for the 1st drug on board given that the epi could have increased 02 consumption and post arrythmias? Half life?

    • says

      Vasopressin can replace the first or second dose of epinephrine, but us used only one time due to the long half-life. It is considered a equivalent first drug of choice with epinephrine. Epinephrine remains on an equivalent level most likely due to its wide spread and short duration of action.
      Kind regards,
      Jeff

  5. says

    My trainer at work said the next round of ACLS indicates that vasopressin may be administered during cardiac arrest at any time, instead of replacing a round of epi. I can’t seem to find ligature for this. I understand the desire to get it on board Asa p, this the emphasis on replacing the first or second round, but what about a 3rd or fourth round? Or at the same time as a round of epi?

    Our area is a good 25 minutes from the closest receiving facility, and that’s going lights and sirens. It’s not abnormal for us to defibrillate pts 9 times or more, and get 4+ rounds of epi on board. Only over the past month has our local protocols changed over to no transport unless ROSC is achieved, mainly because of our long transport times. Ideally, they want us heading towards a facility ASAP to reduce time of post cardiac arrest treatment, and faster delivery times to the ER.

  6. says

    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

  7. says

    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

    • says

      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

    • says

      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

  8. says

    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?

    • says

      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

  9. scrock says

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

    • says

      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

  10. says

    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.

  11. says

    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.

    • says

      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

    • says

      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

  12. says

    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?

    • says

      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

  13. Jenn K says

    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!

    • says

      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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