ACLS and Vasopressin (2023)

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.

(Video) ACLS Alpha Beta Adrenergic agents dopamine and Vasopressin use by Nik Nikam MD

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.

(Video) Epinephrine (ACLS Pharmacology)

ACLS and Vasopressin (1)

(Video) Post Cardiac Arrest - ACLS Review

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.)

(Video) Tachycardia Algorithm - ACLS Review

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.

(Video) Dopamine (ACLS Pharmacology)

Trivia: Another name for vasopressin is antidiuretic hormone (ADH).

(Video) Amiodarone (ACLS Pharmacology)


Vasopressin may be given IV/IO or by endotracheal tube.

(Video) VASOPRESSIN in Emergency Medicine and ALS


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.

(Video) Vasopressors Explained Clearly: Norepinephrine, Epinephrine, Vasopressin, Dobutamine...


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.

How much vasopressin do you give in a code? ›

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

Why is vasopressin no longer used? ›

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.

How often can vasopressin be given during CPR? ›

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.

Why use vasopressin instead of epinephrine? ›

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.

What can you use instead of epinephrine in ACLS? ›

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.

What is the starting rate for vasopressin? ›

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.

Can vasopressin be given as a bolus? ›

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.

How fast can you titrate vasopressin? ›

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.

When was vasopressin removed from ACLS? ›

Vasopressin was removed from the American Heart Association Adult Cardiac Arrest Algorithm in 2015 when initial trials32,33 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.

Can you give vasopressin IV push? ›

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.

How long does vasopressin take to act? ›

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.

What happens if you give too much vasopressin? ›

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.

When should you not use vasopressors? ›

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.

When is vasopressin indicated? ›

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.

Why is vasopressin used in ICU? ›

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.

How do I remember ACLS drugs? ›

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.

What drug is no longer used in ACLS? ›

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.

What is the first drug used in ACLS? ›

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.

How do you calculate vasopressin drip? ›

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

Which vasopressor to use first? ›

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

How do you dilute vasopressin for IV push? ›

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.

Is vasopressin given in units or 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.

Can vasopressin go through a peripheral IV? ›

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.

Should you titrate vasopressin? ›

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.

Does vasopressin increase preload or afterload? ›

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).

Does vasopressin increase heart rate? ›

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

What is the difference between ACLS 2015 and 2020? ›

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.

What happens if vasopressin is not released in case of diuresis? ›

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.

What is the most recent ACLS update? ›

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.

What rhythm is not shockable? ›

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.

What drugs are used in ACLS? ›

  • Commonly Used Medications in ACLS.
  • Adenosine.
  • Amiodarone.
  • Atropine.
  • Dopamine.
  • Epinephrine.
  • Lidocaine.
  • Magnesium Sulfate.

How many units of vasopressin per minute? ›

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.

How does vasopressin make us feel? ›

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).

How do you stimulate vasopressin? ›

Factors That May Increase Vasopressin (AVP Promoters)
  1. Restricting water.
  2. Dietary Sodium [19]
  3. Standing [20]
  4. Exercise [21]
  5. Sauna [22]
  6. Forskolin/cAMP [23]
  7. Glycine [24, 25]
  8. Rhodiola – Lowers endopeptidase activity, leading to higher vasopressin. Rhodiola sacra [26] and Rhodiola sachalinensis [27].
Dec 15, 2022

What is the antidote for vasopressin? ›

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.

Does vasopressin affect cardiac output? ›

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.

What is the recommended alternative to vasopressor infusion in the management of unstable bradycardia unresponsive to atropine? ›

Epinephrine and Dopamine

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

What is vasopressin most responsible for? ›

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).

What does vasopressin do to the heart rate? ›

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

Why do you give fluids before vasopressors? ›

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.

What medication is given for poor perfusion ACLS? ›

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

What is the most common vasopressor used in advanced cardiac life support? ›

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.

What is the vasopressor of choice if MAP remains low despite fluid resuscitation? ›

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.


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