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.
Haley Culler says
Hi Jeff.
Is vasopressin going to be taken out of ACLS protocol? If so, how soon?
Thanks,
Haley
Jeff with admin. says
Yes, vasopressin is going to be removed from ACLS protocol. This change along with the other guideline changes will take affect when the new provider manuals are released with an March-April 2016 time frame.
Kind regards,
Jeff
philllip patterson says
I order medical supplies for a ACLS ambulance district. Boundtree Medical [largest supplier] in the U.S. just called me and advised that it no longer stocks non refrigerated Vassopressin. What is the plan for pre-hospital Vasopressin?
Jeff with admin. says
I’m pretty sure that vasopressin is going to be phased out of ACLS protocol in the near future. You probably will not have to stock it on your ambulances after this time.
Kind regards,
Jeff
Pradeep Pathak says
Hi Jeff,
I like the contents on this website very much. I would like to ask is that 1st dose of Amiodarone is given after the 3rd shock, so the 2nd dose is given after the 4th shock or 5th shock?
I mean to say that the Algorithm is 1st shock- 2nd shock – Epinephrine-3rd shock – Amiodarone- 4th shock-Amiodarone or after 4th shock it is Epinephrine and Amiodarone after 5th shock.
regards
Pradeep
Jeff with admin. says
The second dose of amiodarone can be given after the fourth or fifth shock. It is really up to the discretion of the provider whether they give the amiodarone after the fourth or fifth shock.
Kind regards,
Jeff
MACKY says
Vasopressin can replace the first or second dose of epinephrine. My question is why are we giving it in the initial phase of resuscitation only( First or Second dose of epinephrine)? Why can’t we give it in replacement of subsequent doses of epinephrine?
Jeff with admin. says
The half-life of epinephrine is 2 minutes. This is why you give the medication every 3-5 minutes.
It is the same with vasopressin. The half-life of vasopressin is 20 minutes. This is why it can be given only one time during a code as a replacement for the first or 2nd dose of epinephrine.
Kind regards,
Jeff
Michael says
Why is the 1st epinephrine given after the 2nd shock? If circumstances are right, say in a hospital or in the middle of transport, and an IV is already in place, why not give the epinephrine after the 1st shock?
Jeff with admin. says
The algorithm is designed to start at the very beginning with no IV access and no drugs available. It is given after the 2nd shock of the algorithm so as to emphasize the CPR and shocks which are the only interventions that have been shown to improve survival to hospital discharge. This algorithm is not all inclusive and can be “tweaked” if the situation allows. The algorithm itself is generic and does not take into consideration many of the variables that can exist in a real code setting.
AHA states that health care providers can tailor the sequence of events to the situation at hand. Very often, I have seen epinephrine given very early in a code when extra hands were available and an IV was already in place. If you only have two people available, the pushing of medications will not be of primary importance and will not take place before the 2nd shock because the two people will be performing other more critical interventions.
Kind regards,
Jeff
Louis says
Epinephrine is also naturally released by the body during defibrillation and so is not always necessary until after the second shock. My personal choice is vasopressin over epinephrine anyway as some studies have shown it to cause less side effects and theoretically iincreass cerebral perfusion .
Elizabeth Novotny says
In the pre-course assessment for the AHA on-line it asks the question…in pulseless vtach a patient has received one dose of epinephrine and two shocks, the next medication to expect should be amiodarone. I do not understand why vasopressin is not the correct medication . Could you explain this to me? I cannot thank you enough for this course, and your help! It has been wonderful!
Thank you and God bless,
Elizabeth
Jeff with admin. says
Epinephrine is given after the second shock. Any subsequent doses of epinephrine are given every 3 to 5 minutes. Epinephrine is basically on it’s own timetable after the initial dose.
The first dose of Amiodarone is always given after the third shock. Any subsequent dose of amiodarone is given after the first dose has had adequate time to circulate. This usually occurs any time after the fourth shock, but always during CPR.
Kind regards,
Jeff
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
Jeff with admin. 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
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
Jeff with admin. 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
Colleen says
Now with Vasopressin moving to a product that must be in the refrigerator, what is everyone doing for the crash carts???
Jeff with admin. says
The vasopressin that we carry does not require refrigeration. Maybe your facility needs to stock a brand that does not require refrigeration.
Kind regards,
Jeff
Linda 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.
Bert Johnson says
Been a paramedic for 26 years, Vasopressin is the bomb….kept ppl in V-fib forever….
William says
Why is Mag Sulfate considered after an antiarythmic is given in the pulseless arrest VF or VT algorhythm
Jeff with admin. 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
laura 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 ??
Jeff with admin. says
That is correct. Give the epi with CPR after the 2nd shock.
Kind regards, Jeff
Paul 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
Jeff with admin. 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
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?
Jeff with admin. 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
kimmeyers says
why is vasopressin only allowed once?
Jeff with admin. says
Vasopressin is only given once because the half-life of vasopressin is around 20 minutes.
Kind regards,
Jeff
Kory 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.