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.
Fran giles 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
Jeff with admin. says
Theoretically, if a code lasted that long I suppose that you could give vasopressin a second time. The dose frequency is strictly related to the half-life.
Kind regards,
Jeff
Jamie Dora 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
Jeff with admin. 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
Jeff with admin. 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
John Fisher 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?
Jeff with admin. 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
scrock says
When substituting vasopressin for epinephrine do you have to wait 10 minutes before the next epinephrine ?
Jeff with admin. 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
soumya anand says
Can we push vasopressin dierect, without any dilution?
Jeff with admin. says
Yes, vasopressin can be pushed undiluted. It does need to be followed with a rapid push of 20 ml of normal saline.
Kind regards,
Jeff
soumya's says
Why is vasopression given only once to replace either the first or 2nd dose epinephrine?
Jeff with admin. says
Vasopressin is only given once because the half-life of vasopressin is around 20 minutes.
Kind regards,
Jeff
kurt 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.
Jeff with admin. says
The use of vasopressin IV during cardiac arrest is actually an off label use and all vials of vasopressin show for IM/SQ use (as far as I know).
Kind regards,
Jeff
Tim 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.
Jeff with admin. 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
ed says
i know vasopressin can be used in pulseless v.fib/v.tach, can it also be used in asystole/PEA
Jeff with admin. says
Yes, vasopressin can be used to replace the first for second dose of epinephrine in the asystole/PEA branch of the pulseless arrest algorithm.
Kind regards,
Jeff
cindy s says
I’ve checked 3 sources and none say how fast to push vasopressin. Can you help?
Jeff with admin. 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
Nick 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?
Jeff with admin. 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
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!
Jeff with admin. 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
Brittany says
I have heard that after giving a dose of vasopressin another vasopressor (epinephrine) isn’t needed for another 10 minutes (instead of the 3-5 minutes epinephrine suggests), is this true? If so, what evidence supports this?
Thanks!
Jeff with admin. says
Vasopressin should only be administered once because, the half-life of vasopressin is 10-35 minutes. This means that it will remain in the system for at least 20 minutes.
The reason why epinephrine is give every 3-5 minutes is that the half-life of is 2-3 minutes. This means that it will remain in the system for at least 4 minutes.
Vasopressin should only need to be given once during a code.
Kind regards,
Jeff
Josiah EMT says
The asystole/PEA algorithm says Epi should be used 3-5 mins after Vasopressin. Are you saying we should wait 20 mins before administering Epi? Does this produce a “stacking” effect or are they complementary?
Jeff with admin. says
Vasopressin can be used once in replace of the first or second dose of epinephrine. After the vasopressin is given, the epinephrine is given 3-5 minutes later, and after this, the epinephrine is continued every 3-5 minutes. Only one dose of vasopressin would be used in most arrest scenarios.
Kind regards,
Jeff
Josiah EMT says
P.S. When I say “stacking” I am referring to toxicity, such as with Amiodarone.
Jeff with admin. says
You would not have any problems repeating the epinephrine 3-5 minutes after vasopressin. If you repeated the vasopressin, you would have a build-up in the system since the half-life of vasopressin is much longer.
Kind regards,
Jeff
mebuchanan7 says
Thank you for this site!!!
BearRN61 says
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)
…….
In the set you give above, you state that Epi is now on its’ own time table . . .so where does the dosing of the Epi fit in for the second, third, fourth doses etc. especially since you are attempting amiodarone in the sequence . . .it just seems that a dose of epi would be appropriate before the first dose or after the amiodarone and before the Rhythm analysis after the first dose of Ami . . .is that correct? or am i reading too much into it .. .?
Jeff with admin. says
The first dose of epinephrine is given after the 2nd shock during CPR. After this it is given every 3-5 minutes.
The first dose of amiodarone is given after the 3rd shock during CPR.
No need to read into it any more than that.
Kind regards,
Jeff
Heather says
Vasopressin is on manufacturer back order and we need to update crash cart. Ephedrine has been suggested, is this correct? If so, what is the dosage?
Jeff with admin. says
I have not seen ephedrine suggested as a replacement for vasopressin. Within ACLS protocol the first line drugs are epinephrine and vasopressin. If you don’t have vasopressin, use epinephrine.
Kind regards,
Jeff