Vasopressin
We are now left with a difficult choice, deciding on which drugs can help us resuscitate someone while preserving their quality of life, and more and more it seems these goals are at odds with each other - Dr. Wm. Ken Milne
image by: David Cordova Flores
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How Did I Get Epi Alone? Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrests
Answering clinical questions about cardiac arrest with clinical trials has always been fraught with difficulty. However, cardiac arrest is something we regularly treat in the emergency department, and we need more high-quality data to inform our care. Vasopressin had been included as a part of the American Heart Association (AHA) ACLS protocol for quite a while but was removed in favor of a vasopressor monotherapy strategy with epinephrine.
The tide now is shifting in resuscitation research to shift our focus from obtaining ROSC to measuring functionality and good neurologic outcomes. In the context of questioning epinephrine’s role in ACLS after Paramedic2, we look at using the…
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Vasopressors in the ED
Vasopressin: ONE LINER: SUPPLEMENTAL VASOPRESSOR, NEVER AS A SINGLE AGENT - Mechanism: Vasoconstriction via Vasopressin (V1) receptor - Dose: Fixed dose 0.03U/min, no titration. Can use 20U as single bolus in cardiac arrest with steroids (VSE 2013) - Indication: Shock (septic, vasodilatory), renal failure - Good/bad: (+) No adrenergic activity – no arrhythmias, does not compete with catecholamines (+) Maybe decrease need for dialysis compared to norepi (VANISH Trial). (-) No mortality benefit compared to Norepi.
Adrenaline and vasopressin for cardiac arrest
Vasopressin compared to standard dose adrenaline improved survival to admission but not return of spontaneous circulation, whilst the combination of adrenaline and vasopressin compared with adrenaline alone had no effect on these outcomes. Neither standard dose adrenaline, high‐dose adrenaline,vasopressin nor a combination of adrenaline and vasopressin improved survival with a favourable neurological outcome. Many of these studies were conducted more than 20 years ago. Treatment has changed in recent years, so the findings from older studies may not reflect current practice.
The Vasopressor Toolbox for Defending Blood Pressure
All in all, vasopressin has been shown to be as safe as norepinephrine at lower doses and remains a key component of the vasopressor toolbox. Vasopressin is not titrated to clinical effect as are other vasopressors and could be thought of more as a replacement therapy and treatment of relative vasopressin deficiency. The 2016 Surviving Sepsis Campaign Guidelines suggest adding vasopressin (doses up to 0.03 units/min) to norepinephrine to help achieve MAP target or decrease norepinephrine dosage
Under Pressure Journal Club (Vasopressin, Steroids and Epinephrine in Cardiac Arrest
This was a bold study and the results are exciting. For in-hospital cardiac arrest, the VSE protocol has been shown to improve survival to hospital discharge with good neurological outcomes which is perhaps one of the most relevant patient-centered outcomes.
Vasopressin in pediatric shock and cardiac arrest
: Vasopressin offers promise in shock and cardiac arrest in children. However, in view of the limited experience with vasopressin, it should be used with caution.
How Did I Get Epi Alone? Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrests
Intervention: Vasopressin 20 IU and methylprednisolone 40 mg given as soon as possible after first dose of epinephrine, followed by vasopressin 20 IU after each epinephrine up to four doses. We still do not have high-quality, clinically relevant information to support the use of vasopressin, steroid, and epinephrine (VSE) protocol in patients with IHCA. That does not mean VSE should never be used and it will depend also on the clinicians’ judgment. We are now left with a difficult choice, deciding on which drugs can help us resuscitate someone while preserving their quality of life, and more and more it seems these goals are at odds with each other.
ScienceDirect
Vasopressin (AVP) is a polypeptide containing nine amino acids, with a disulfide bridge between cysteine residues, which has important antidiuretic and vasopressor actions and a variety of other actions including glycogenolysis.
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