ACLS and Vasopressin
Vasopressin has been removed from the AHA ACLS Cardiac Arrest Algorithm and is no longer used in ACLS protocol.
Clinical studies have shown that both epinephrine and vasopressin are effective for improving the chances of return of spontaneous circulation during cardiac arrest.
The removal was due to the fact that there is no added benefit from administering both epinephrine and vasopressin as compared with administering epinephrine alone, and in order to simplify the algorithm, vasopressin was removed.
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.
Joe says
ER Dr W. Where is the official literature supporting epi administration q 3-5 minutes regardless of vasopressin in the pulseless arrest? This is a topic of controversy in my department. Thanks.
Jeff with admin. says
The administration of vasopressin replaces the 1st or 2nd dose of Epinephrine.
So the scenario would like this:
Vasopressin (3-5min wait) —Epinephrine (3-5 min wait) —- Epinephrine (3-5 min wait)— Epinephrine (3-5 min wait)….
Or like:
Epinephrine (3-5 min wait)— Vasopressin (3-5min wait) —- Epinephrine (3-5 min wait)— Epinephrine (3-5 min wait)….
The following quote if from here When you get to that page, press the control button F button to open the find function in your browser. Type in vasopressin and it will find every instance of the word in the document.
Kristina Reigelman says
What is the rationale for waiting until after the 2nd shock to give epi? Why can’t it be given immediately?
Jeff with admin. says
“Because defibrillation is the definitive therapy for VF, vasopressor and antiarrhythmic agents should be given only when defibrillation and CPR are ineffective and VF or pulseless VT persists. The ACLS Pulseless Arrest Algorithm directs providers to administer a vasopressor and consider antiarrhythmia therapy after shocks and CPR fail to restore a perfusing rhythm.”—pg. 68, ACLS Resource Text for Instructors and Experienced Providers.
Kind regards,
Jeff
Abdul Azeez RN says
Why it is recommented to give Inj.epinephrine 1st dose only after second shock during cardiac arrest? is there any reason for that?
Jeff with admin. says
“Because defibrillation is the definitive therapy for VF, vasopressor and antiarrhythmic agents should be given only when defibrillation and CPR are ineffective and VF or pulseless VT persists. The ACLS Pulseless Arrest Algorithm directs providers to administer a vasopressor and consider antiarrhythmia therapy after shocks and CPR fail to restore a perfusing rhythm.”—pg. 68, ACLS Resource Text for Instructors and Experienced Providers.
Kind regards,
Jeff
Jonathan says
Still not clear that if you are in vfib then asystole/PEA arrest, and you sequence:
rhythm analy VF
Shock
rhthm analy VF
2 min cpr
rhthm analy VF
2 min cpr epi
rhthm analy VF
2 min cpr amio
rhthm analy VF
2min cpr epi
rhythm analy PEA
2min cpr
rhythm analy PEA
2 min cpr…. can I now replace the 1st epi dose in the asystole/pea algorithm with vasopressin?
Or can I only replace 1st or 2nd epi from the total code with Vasopressin?? Thanks
Jeff with admin. says
Your question about vasopressin is correct. However in your sequence above, you do not to a rhythm analysis after a shock, you should immediately perform 5 cycles of CPR. Also you were missing several shocks. Below is the correct sequence:
Rhythm analysis VF
Shock
2 min CPR
Rhythm analysis VF
Shock
2 min CPR/epi (once the first dose of epinephrine is given, epi is every 3-5 min on it’s own time-table)
Rhythm analysis VF
Shock
2 min CPR/amiodarone (300mg)
Rhythm analysis VF
Shock
2 min CPR/amiodarone (150mg)
Rhythm analysis Organized rhythm (check pulse-no pulse)
2 min CPR/epi
Rhythm analysis Pea (no pulse)
…….
Kind regards,
Jeff
jonathanjung says
You’re right…. I was cutting and pasting and lost my shocks and the 2 min cpr before the rhythm analysis….. lol
So, vasopressin may be given later in the code if it was not given earlier, as long as it is replacing the 1st or 2nd dose of epi or that particular rhythm I am in.
Just out of curiosity:
1) why can it only replace the 1st or 2nd epi of the VT/VF branch or the 1st or 2nd epi of the Asystole/PEA branch? In other words, would there be harm replacing the 3rd, 4th, etc epi dose if it has not been given earlier?
2) is my understanding correct that one would never give a second dose during the entire code? Thanks, jj
Jeff with admin. says
Yes, vasopressin can be given later in the code if the rhythm changes and you switch to a different branch of the pulseless arrest algorithm.
AHA wants vasopressin given early in a cardiac arrest so that the chances of it being of some benefit would be higher. The longer a patient is in cardiac arrest, the lower the chance of ROSC.
Vasopressin only has to be given once because it has a half-life of 10-20 minutes. The half-life of epinephrine is 2 minutes. and this is why it is given every 3-5 minutes.
Kind regards,
Jeff
jonathanjung says
Thanks…. appreciate your answers!
vasi says
Wats da max dose of epi can be given
Jeff with admin. says
There is no max. dose for epinephrine.
Kind regards,
Jeff
Dara Bass says
what would be the cons to using Vasopressin. Why are you given a choice, what do I need to know to make that decision. If Vasopressin was given can you go right behind it with Epi after the next shock or is there some time limit you must wait before additional medication is given.
Jeff with admin. says
Either Epinephrine or vasopressin can be used. My preference is Epineprine. There realy is no difference other than Vasopressin can be used to replace only the first or 2nd dose of epinephrine. My preference is to just stick with epinephrine for consistence.
Yes if Vasopressin is given as the 1st or 2nd dose, you may follow it in 3-5 minutes with Epinephrine.
There is not any clinical evidence that has shown that either epinephrine or vasopressin improve survival to discharge rates. However, it makes clinical sense to give a vasopressor for multiple reasons. This is why the use of vasopressors continues.
Kind regards,
Jeff
jwardrn says
What are the multiple reasons?
Jeff with admin. says
Multiple reasons for the use of vasopressors in the cardiac arrest setting include.
1. Vasopressors cause increases peripheral vascular resistance (vasoconstriction) which has the effect of shunting blood to the vital organs.
2. Vasopressors increase cardiac output
3. Vasopressors increase systolic blood pressure
4. Vasopressors relax bronchial smooth which results in bronchodilation (improved ventilation)
Kind regards,
Jeff
Jbs says
What is the rationale behind recommending vasopressin replacement of an epi dose, but only during the first or second dose in the code, and not at a later point during resuscitation?
Chris with admin. says
The research that demonstrated a benefit with Vasopressin dealt only with its administration after the first to second defibrillation or another way to say it, before the patient was in refractory VFib. There is no research that has demonstrated efficacy of vasopressin in refractory VFib. —Regards, Chris
John Ynami says
I believe it is because vasopressin has a slow onset and long half life.
Pamela Bradford says
I was told at my ACLS training that Vasopressin is a very good at vasoconstriction, but that it effect also constricts the cardiac vessels and you are partly defeating yourself.
Jeff with admin. says
Each drug does have unwanted effects. Unwanted affects of epinephrine and vasopressin are minimal this is why they are first line drugs.
Kind regards,
Jeff
Jane Snatic says
Where is the information of vasopressin causing cerebral vessel dilation and increased cerebral blood flow?
Brandon Dahl says
Here is an article that mentions it and I found helpful. Hope it helps.
Christine says
SO VASOPRESSIN IS TO BE USED ONLY ONCE DURING THE WHOLE CODE EPISODE AS A REPLACEMENT FOR THE FIRST OR SECOND OF EPINEPHERINE?
Jeff with admin. says
That is correct.
Ryan Tyler says
In a patient with a suspected head bleed that codes, would Vasopressin be “less” indicated because of the cerebral vessel dilation?
Jeff with admin. says
Per my brother Chris, He says: “I think I can safely say that there is no literature that would be for or against the use of vasopressin in this situation. Though, my guess would be that most providers would chose to use epinephrine.” –Jeff
mmmmmapn says
yes – but remember that it is choice over dopamine for esophageal varices that bleed to the point of resusitation.
R says
Hi–For asystole treatment, you have said that CPR and epi are what you need. On the “ACLS Drugs” page, you have epi and vasopressin. These are all still correct I assume? Thanks. Love your site!!
Jeff with admin. says
Yes, epinephrine and vasopressin are acceptable with asystole. See page 88 in the AHA provider manual.
Kind Regards,Jeff
Clayton O'Brien says
If it is recommended that Vasopressin is given IV/IO, why does the manufacture state on the vial that it is only for IM or SC only? It doesn’t even say it is intended for IV/IO use.
Chris with admin. says
You are correct. The manufacture does state that it is for IM/SC only. The use of vasopressin IV in cardiac arrest is considered “off label” use. The literature has found vasopressin to be as safe and effective as epinephrine, and it is currently given a class IIb (acceptable, safe and useful). There is no advantage of using vasopressin over epinephrine. Here’s a link to a recent review of literature that I thought was insigntlful. Does Vasopressin Improve Survival?
Thanks. Chris
Jessica says
Deb Thank you so much for this question. I have been wondering if you have to wait 20 minutes before giving epi again. I am glad that I am not the only one out there confused by the way the algorithm is worded.
Thank you for the answer Dr W. Very helpful
ER Dr W says
@Deb:
No, if you look at your algorithms it merely replaces either the first or second dose of epinephrine. You should continue to give epi as if you had never given vasopressin each subsequent time period it is due(every 3-5 minutes).
– Dr W
Deb VanElzen says
Is it recommended to wait 20 minutes after giving Vasopressin to administer Epi?
PMDJ says
THERE IS NO HARM IN FOLLOWING EPI IN 3-5 MIN AFTER GIVING VASOPRESSIN. VASOPRESSIN IS RECOMMENDED IN THE BEGINNING DUE TO ITS BENEFITS AND ITS HALF-LIFE. AFTER GIVEN PRETEND YOU DONT EVEN HAVE THE DRUG ON BOARD AND CONTINUE WITH YOUR EPI. BUT DONT FORGET TO DOCUMENT THE VASOPRESSIN