ACLS and Vasopressin (2023)

FAQs

Is vasopressin still recommended in ACLS? ›

The benefits of epinephrine support the recommendation for its use, despite some remaining uncertainty about overall impact on neurological outcome. epinephrine remains unchanged. Vasopressin may be considered in cardiac arrest, but it offers no advantage as a substitute for epinephrine.

The current cardiopulmonary resuscitation guidelines recommend intravenous vasopressin 40 IU or epinephrine 1mg in adult patients refractory to electrical countershock.

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.

We suggest alternating injections of 1 mg epinephrine i.v. and 40 IU vasopressin i.v. every 3–5 minutes during CPR until spontaneous circulation can be achieved or CPR efforts are terminated.

As has been shown in an in vitro study, vasopressin has vasoconstricting efficacy even in severe acidosis, when catecholamines are less potent. Thus, vasopressin may be a more effective vasopressor than epinephrine in patients with asystole, resulting in better coronary perfusion pressure during cardiac resuscitation.

The American Heart Association's (AHA) most recent Advanced Cardiac Life Support (ACLS) guidelines recommend vasopressin as an alternative to epinephrine in the treatment of cardiac arrest.

Vasopressors are utilized after adequate fluid resuscitation to achieve a mean arterial pressure (MAP) goal of 65 mmHg. The Surviving Sepsis Guidelines recommend a vasopressin rate of up to 0.03 units/minute, however in clinical practice a rate of 0.04 units/minute is commonly used.

Although vasopressin infusions have been used in a variety of other situations, there are limited data to guide bolus dosing. Others report lower doses of vasopressin bolus. A 2-U bolus dose was used to treat anaphylactic shock.

It can be titrated up by 1-2 mcg/min every 20 minutes until the desired effect or hemodynamic stability. However, more is not better. High doses do not improve outcomes and can cause post-resuscitation myocardial dysfunction.

Vasopressin was removed from the American Heart Association Adult Cardiac Arrest Algorithm in 2015 when initial trials^32,33 failed to demonstrate significant benefit for vasopressin compared with or in addition to epinephrine.

What has changed in ACLS? ›

Major new changes include the following: Enhanced algorithms and visual aids provide easy-to- remember guidance for BLS and ACLS resuscitation scenarios. The importance of early initiation of CPR by lay rescuers has been re-emphasized.

During open abdominal aortic aneurysm surgery, patients will sometimes develop hypotension not responsive to catecholamines during bowel retraction. I will then administer 1 or 2 boluses of vasopressin, 0.4 U, by IV push. This is typically sufficient to treat the hypotension.

Onset of the pressor effect of vasopressin is rapid, and the peak effect occurs within 15 minutes. After stopping the infusion the pressor effect fades within 20 minutes.

If your body produces too much vasopressin, your kidneys may retain water. A condition called syndrome of inappropriate antidiuretic hormone secretion (SIADH) can occur when the body produces too much vasopressin. In SIADH, excess water retention dilutes the blood, resulting in a low sodium concentration.

Vasopressor use in severely injured trauma patients is discouraged due to concerns that vasoconstriction will worsen organ perfusion and result in increased mortality and organ failure in hypotensive trauma patients.

Vasopressin is indicated for prevention and treatment of postoperative abdominal distention, in abdominal roentgenography to dispel interfering gas shadows, and in diabetes insipidus. Vasopressin is available under the following different brand names: Vasostrict, and ADH.

The rationale for use of vasopressin in the ICU is that there is a vasopressin deficiency in vasodilatory shock and advanced shock from any cause and that exogenously administered vasopressin can restore vascular tone.

For example, one of the common methods used to remember the treatment options for the algorithm Bradycardia is All Tall Dogs Eat, , which translates to Atropine, Transcutaneous Pacing, Dopamine, and Epinephrine.

Secondly, similar to atropine, vasopressin has been removed from the ACLS algorithm not because of evidence showing harm, but rather evidence showing a lack of clear benefit.

Adenosine. This anti-arrhythmic is most commonly used for supraventricular tachycardia. It should be given rapidly for the first dose, and a second dose may follow.

What are the guidelines for use of vasopressin? ›

Dosing Range: The usual therapeutic dose is between 0.1 and 1.2mU/kg/min. Recommended starting dose is 0.3mU/kg/min with titration up every 15-60 minutes [depending on the magnitude of the illness severity] in intervals of 0.2-0.3mU/kg/min to achieve target arterial pressure.

Calculation of drip rate: 50 mg/250ml (ml/hr) = wt (kg) x 0.3 x mcg/kg/min.

Experts' recommendations currently position norepinephrine (NE) as the first-line vasopressor in septic shock.

For doses and rates LESS than 1.8 units/hr (1.8 mL/hr) prepare: Vasopressin 20 units (1 mL from ONE ampoule) diluted to 20 mL with glucose 5% in a luer lock syringe. Total Volume: 20 mL. Final concentration: 1 unit/mL.

Dosage Forms And Strengths

Vasostrict^® (vasopressin injection, USP) is a clear, practically colorless solution available as 20 units/mL in a single dose vial and 200 units/10 mL (20 units/mL) in a multiple dose vial. To be used after dilution.

Recent studies have suggested that vasopressor administration via peripheral intravenous catheters (PiVCs) may be a feasible and safe alternative. This systematic review evaluates the safety of delivering vasopressor medications via PiVCs.

Several studies published this year support the hypothesis that vasopressin should be used as a continuous low-dose infusion (between 0.01 and 0.04 U/min in adults) and not titrated as a single vasopressor agent.

Physiologic effects: It increases systemic vascular resistance (SVR). It does cause venoconstriction, which may increase preload. Its dominant effect on cardiac output is often to cause a reduction (but this may depend on the heart's ability to tolerate increased afterload).

It is known that vasopressin decreases PRA and heart rate and increases blood pressure and plasma corticosteroid concentration.

1. There were no changes to the 2015 cardiac arrest algorithms. 2. The 2020 adult bradycardia algorithm increased the atropine dose to 1 mg (from 0.5-1 mg) but maintains the same frequency of dosing as every 3-5 minutes with max dose of 3 mg.

Which vasopressor should be discontinued first? ›

CONCLUSION. Discontinuing VP first may lead to a higher incidence of hypotension but has not been associated with poor outcomes in septic shock patient who receives concomitant VP and NE therapy. The use of corticosteroids may mitigate this effect.

Deficient VP release causes the syndrome of diabetes insipidus, which is characterized by insatiable polydipsia and persistent inappropriately dilute urine in the presence of strong osmotic stimuli for VP release.

The 2021 ACLS guidelines have been in effect since October 2020 when the American Heart Association released the most recent guidelines changes for BLS, ACLS, and PALS. Furthermore, these guidelines will be good through 2025 when the AHA meets again to update the guidelines.

Rhythms that are not amenable to shock include pulseless electrical activity (PEA) and asystole. In these cases, identifying primary causation, performing good CPR, and administering epinephrine are the only tools you have to resuscitate the patient.

Abstract. Background: Arginine vasopressin (AVP) is suggested as an adjunct to norepinephrine in patients with septic shock. Guidelines recommend an AVP dosage up to 0.03 units/min, but 0.04 units/min is commonly used in practice based on initial studies.

Vasopressin is associated with physical and emotional mobilization and helps support vigilance and behaviors needed for guarding a partner or territory (3), as well as other forms of adaptive self-defense (103).

Demeclocycline and lithium

Demeclocycline, a tetracycline antibiotic, is sometimes used to block the action of vasopressin in the kidney in hyponatremia due to inappropriately high secretion of vasopressin (SIADH), when fluid restriction has failed.

High dose of vasopressin (greater than 0.15 UI/min) resulted in a decrease in cardiac output, oxygen consumption and in regional organ blood flow [21, 22]. When lower doses of vasopressin were tested (less than 0.1 U/min), mean arterial pressure was increased, without detrimental effect on cardiac output [23].

What happens to blood pressure when injected with vasopressin? ›

Vasopressin injection is also used to increase blood pressure in adults with vasodilatory shock (eg, post-cardiotomy, sepsis) who remain to have low blood pressure after receiving fluids and medicines. Vasopressin is a hormone that is produced in the body. It acts on the kidneys to reduce the flow of urine.

Epinephrine and Dopamine

They are both used as infusions in the bradycardia algorithm if atropine is ineffective.

Vasopressin or antidiuretic hormone is a potent endogenous hormone which is responsible for regulating plasma osmolality and volume. It acts as a neurotransmitter in the brain to control circadian rhythm, thermoregulation, and adrenocorticotrophic hormone release (ACTH).

It is known that vasopressin decreases PRA and heart rate and increases blood pressure and plasma corticosteroid concentration.

The basic theory behind giving IV fluids prior to vasopressors is that septic patients are often intravascularly volume depleted due to third-space losses, and there is concern that arterial constriction alone could impair perfusion.

If poor perfusion present, administer atropine. If adequate perfusion present, monitor and observe.

In summary, vasopressin is an effective vasopressor and can be used as an alternative to epinephrine for the treatment of adult shock-refractory VF (Class IIb: acceptable; fair supporting evidence). Vasopressin may be effective in patients with asystole or pulseless electrical activity as well.

In practice, we recommend norepinephrine as first choice vasopressor in septic and vasodilatory shock after adequate volume resuscitation. In norepinephrine-refractory patients, vasopressin or epinephrine may be added.