Vasopressin Vs. Epi

Sasha

Sasha

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Today in class we were discussing Epi Vs. Vasopressin, all the medic instructors were in agreement that they don't like vasopressin, and only one had it in their local protocol. However vasopressin seems to have more positive effects than just epi alone.
Vasopressin Vs. Epinephrine
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2447575
Vasopressin also has a vasoconstrictive action in the vascular network of the skeletal muscles, bowel, fat tissue, skin and, to a lesser degree, the coronary and renal vessels, while it causes vasodilation in the brain vessels. This results in an increase of the coronary perfusion pressure and, in general, an increase of blood flow to the vital organs without causing a dramatic increase in the myocardial oxygen consumption
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And seems to be more successful than just epi alone.
Methods
Ventricular fibrillation was induced in 22 Landrace/Large-White piglets, which were left untreated for 8 minutes before attempted resuscitation with precordial compression, mechanical ventilation and electrical defibrillation. Animals were randomized into 2 groups during cardiopulmonary resuscitation: 11 animals who received saline as placebo (20 ml dilution, bolus) + epinephrine (0.02 mg/kg) (Epi group); and 11 animals who received vasopressin (0.4 IU/kg/20 ml dilution, bolus) + epinephrine (0.02 mg/kg) (Vaso-Epi group). Electrical defibrillation was attempted after 10 minutes of ventricular fibrillation.


Results
Ten of 11 animals in the Vaso-Epi group restored spontaneous circulation in comparison to only 4 of 11 in the Epi group (p = 0.02). Aortic diastolic pressure, as well as, coronary perfusion pressure were significantly increased (p < 0.05) during cardiopulmonary resuscitation in the Vaso-Epi group.
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I'm curious to know how many people's protocols use vasopressin and if it's a drug they feel is effective in their experience.
 
The last study I read stated that there wasnt any data that suggested one was better than the other. My service does not carry it because I personally feel it is not cost effective to carry both. If you take into considertaion that usually you will still have to give epi after vasopressin, ie. a cardiac arrest that is worked for longer than 20 minutes, and you usually have to draw up the vasopressin vs prefilled epi I think that its not clinically sound to carry both. My opinion is from the evidence based medicine that I am aware of.
I think its a moo point to carry both but there is a handful of EMS services that I know that carry both.
 
I'm aware that Vasopressin is just a one time dose and you still have to use epi, but as oppose to epi alone, granted I haven't spent a long time researching it but the few studies I've read have been positive. How much more expensive is Vasopressin?
 
Cardiologist tend to disagree. One of our premier Heart Hospitals that perform a lot of research found that Vasopressin was one of the few drugs that did work; but the dosage was almost doubled than the recommended dosage. They as well believe ACLS form AHA is a joke.

Personally, I have found Vasopressin much more active in producing fine V-fib to course V-fib and as well, one does not have to repeat every 3 minutes alike Epi as the first round. One can prepare the patient for transport and by that time, it is ready to transport.

R/r 911
 
It was The New England Journal of Medicine july 2008 study that found this conclusion
 
dmiracco said:
It was The New England Journal of Medicine july 2008 study that found this conclusion
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Do you by chance have a link to that study? I'd like to read it!
 
I feel bad for the 22 Landrace/Large-White piglets.
 
I've never used Vasopressin, but I've heard about several studies that indicated that Vasopressin and Epi had statistically equal patient discharge rates. Essentially, it didn't matter if the patient was given Vasopressin or Epi, the same number of patients lived long enough to be discharged from the hospital.

I was also told that they had changed ACLS and that now you can give Vasopressin instead of the first or second dose of Epi, but you also keep giving Epi q3-5. Has anyone else heard this?
 
Sasha, here's the NEJM study

http://content.nejm.org/cgi/content/abstract/350/2/105

There's another one from 04 that was referenced in this one - found that VP was better than EPI for systole, no significant difference in any other dysrythmia.

Differences between the two:

the 04 article has less stastical power than the 08 article (or so they claim, I'm not enough of a stastician to disagree)

Apparently there is a big difference in AED usage as well. The 08 trial was done in France, and I guess they have a really good AED access program. Thus the observed instances of Vfib in that trial were lower, but I can also envision that many patients who might have progressed from vfib to asystole before ALS got on scene were converted early and possibly prevented from going asystolic in the 08 study...that tampers with the number some.


still, interpreting these data can be difficult - there is much data in conflict. Porcine studies seem to like VP alone or in combination, and have the strength of being well controlled studies but the drawbacks of variable physiology when compared to humans. Human studies aren't quite so well controlled but are done in humans, and are pretty variable. Once again, they confirm good CPR and early defib. are key...the difference between VP and EPI may be a drop in the bucket in the end.

By the way, I have issues with the "control" group used in the porcine study cited by Sasha (and several others on the same topic). I think there should have been an additional group with an increased EPI dosage to control for the possibility that better VP outcomes were simply due to additive generic pressor effects, rather than a specific effect of VP. Instead the study compared a single pressor dosage (EPI) to that pressor dosage plus a dosage of another pressor (VP). eh.
 
Aidey said:
I've never used Vasopressin, but I've heard about several studies that indicated that Vasopressin and Epi had statistically equal patient discharge rates. Essentially, it didn't matter if the patient was given Vasopressin or Epi, the same number of patients lived long enough to be discharged from the hospital.

I was also told that they had changed ACLS and that now you can give Vasopressin instead of the first or second dose of Epi, but you also keep giving Epi q3-5. Has anyone else heard this?
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The normal dosage is 40 units of Vasopressin IV, and one can hold Epi up to 10 minutes. Then start administering Epi q 5 minutes, as I described in my previous post. This buys time to prepare the patient for transport and then one can administer the Epi while enroute.

p.s. : High dosage of Epi have been proven to be futile as well.

R/r 911
 
Ridryder911 said:
The normal dosage is 40 units of Vasopressin IV, and one can hold Epi up to 10 minutes. Then start administering Epi q 5 minutes, as I described in my previous post. This buys time to prepare the patient for transport and then one can administer the Epi while enroute.

p.s. : High dosage of Epi have been proven to be futile as well.

R/r 911
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But rid, once my cousin's uncle's nephew's brother's roomate saw high dose epi work when combined with MAST and 12L of infused saline ;)

Sorry I couldn't resist. :ph34r:

But about ACLS from AHA, what I tell the students in ACLS, PALS, and all those other courses. It is not advanced, it is not critical care medicine. It is what to do when you have some toys and are waiting for somebody who really knows what to do.

As for vaso vs. epi, they both have their place.
 
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Just my personal experience... The one time I used Vaso in a code, we got the patient back. The times with epi alone, we didn't. (real scientific I know) Another question, we carried vaso in two 20u vials. Do they even sell it in a 40u vial or pre-filled syringe?
 
Ridryder911 said:
The normal dosage is 40 units of Vasopressin IV, and one can hold Epi up to 10 minutes. Then start administering Epi q 5 minutes, as I described in my previous post. This buys time to prepare the patient for transport and then one can administer the Epi while enroute.
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I'm sorry, I don't think I explained clearly. They were saying the Vaso counted as a dose of Epi, and there was no wait time anymore. You gave the Vaso, and kept the normal Epi every 3-5 minute schedule after that.

Now that I think about it, the three times I've had ACLS they've changed the Vasopressin recommendations. The first time I took it we were taught to give the 40 units of Vasopressin and we didn't have to give Epi again unless the code was more than 40 minutes. Then we were taught to give the Vasopressin, but start giving Epi after 20 minutes. Now I've been told to give the Vasopressin and then just keep giving Epi on scheudle. I wish they would make up their minds!
 
I use vasopressin exclusively as the first line pressor in the cardiac arrests I work, then epi at the appropriate time. In all of the prehospital arrests I have been on that were worked ALS, those patients who were given vasopressin regained a pulse. That's evidence enough for me to use it.

As for the dosage, I can tell you that a progressive OMD for an agency in northern Virginia has his providers give 80 units of vasopressin every 5 minutes throughout the arrest exclusively. Contrast this to AHA's recommendation of 40 units once with another pressor given only after at least 8-10 minutes have passed.
 
I remember reading a paper that said there was a thearetical benefit for using vasopressin for asystole but not a lot of data. I do enjoy that AHA has switched their recommendations so many times. A lot of the people I work with forget that it can be used as the 2nd or 3rd epi dose w/ no need to wait longer than the 3-5m. I have seen it work once or twice. I do not believe they make it in a preject or in a 40u vial...you'd think they would.
 
ACLS a Joke?

While I realize that ACLS may not be the best treatment protocol in the world for all providers, I have a problem describing it as a joke.

Two questions that have are below. Aren't the decisions made by the AHA made by cardiologists? What other program would you suggest for paramedics, nurses, and even non-emergency physicians?

I realize that the 12-lead may be available in some places and not available in others. If your medics don't have 12-lead and can't read them, isn't ACLS about all they have left?
 
medic5740 said:
While I realize that ACLS may not be the best treatment protocol in the world for all providers, I have a problem describing it as a joke.

Two questions that have are below. Aren't the decisions made by the AHA made by cardiologists? What other program would you suggest for paramedics, nurses, and even non-emergency physicians?

I realize that the 12-lead may be available in some places and not available in others. If your medics don't have 12-lead and can't read them, isn't ACLS about all they have left?
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I am not saying ACLS is a joke. What it is used for is imparting the basic information about cardiac emergencies that medical providers that use certain pieces of equipment. What is not supported by scientific research (for whatever reason) standards are made by consensus. Which many times in science has been proven faulty. (Pluto was once a planet) you are right, it is what we have, but it should not be mistaken for true expertise. The vast amount of knowledge required to make ACLS less of a skill set and more of an education cannot be done in 16 weeks, much less 16 hours.

Even the EP class requires knowledge beyond what is taught in national curriculum paramedic classes and the providers you see there are at the very least self educated to a higher standard or have considerable experience. Infact the only 2 medics in the last EP class I was involved in had >16 years experience each. Intending them no disrespect, they were completely lost when we discussed acid/base balance. They were also the only providers (among docs, RNs, and RRTs) arguing for high flow o2 on all patients.
 
I'll say it and will ask others to prove me wrong. AHA ACLS course is a joke!... As one of the first non-physician ACLS instructors now over 28 years, I can attest the courses are not adequate for providers. I administered the test to our hospital janitor and he passed! Now, would you support this course to ensure a provider?

Where did we ever come up with the idea that all those entered the classroom gets to touch patients? The world is harsh, and NO not everyone can be an astronaut nor an emergency care provider.

To answer your questions you asked:

NO! Not all the physicians making the decisions are cardiologist. Thank God! Ever seen a cardiologist run a code... talk about a cluster! As well, many of the cardiologists I have ever met despise AHA and definitely believe ACLS is a joke. Most of the views I have heard was that it now gives a "false security" that many assume they actually know about emergency resuscitation measures and cardiology; when in fact they don't.

What other programs? Instead of diversifying and making multiple courses; let's go back and have one good one. Again in lieu of having money making courses such as the : experienced provider, an advanced airway course, I/O and so on to make more profits, go back to having a credible course. Yes, many might fail... well, so what? They probably should not be performing care then.

Performing and reading ECG is just ONE part of ACLS. Kinda like knowing how to take a blood pressure is not really knowing medicine. If your medics do not know how to assess, obtain a detailed and accurate history, then be able to diagnose and treat an AMI without a XII lead, then they should not be medics.

R/r 911
 
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Ridryder911 said:
I'll say it and will ask others to prove me wrong. AHA ACLS course is a joke!... As one of the first non-physician ACLS instructors now over 28 years, I can attest the courses are not adequate for providers. I administered the test to our hospital janitor and he passed! Now, would you support this course to ensure a provider?
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Rid,

I haven't been an instructor as long as you, but I am not new either. I think the new ACLS is trying to spend some time retraining providers in psychomotor skills/old habits that new science has proven ineffective or harmful. Yes, the test is easy, but I do not think it was meant to be a measure of knowledge. It is sort of like a fire drill. When the alarm goes off can you follow a few simple steps in order to give a patient a chance. Not the best chance, but better than nothing.

Also please consider that not everyone who has to take ACLS, PALS, or any of the other 2 day courses will ever have call to use it. How many providers who work in a doctor's office or non acute setting have we had to teach over the years who are required to have current cert but have never had an emergency in 30 years on the job? (I have had more than a few and I am sure you have had more than me) Truthfully, how many of those people would even remember 5% of what was taught if we extended the course curriculum if they were called upon to use it?

You are 100% right, not everyone is capable of seeing patients. Even fewer are capable of meeting the demands emergent patients place on providers.

We taught one of our janitors how to diagnose STEMI on a 12 lead in a shift. How many providers think that is a complex skill and leave it to the machine to read?

Saying "ACLS is a joke" is not fair, but providers should not hold onto the idea that it is resuscitation education either.(fault the provider not the course) It would be the same as calling yourself a firefighter because somebody let you practice spraying a fire extinguisher after you read and got tested on the directions.
 
Rid and Veneficus-

I asked this once before and didn't get a responce, so here goes again. While paramedic education is lacking in this country, how much of ACLS being dumbed down into the crap that it is now is JCAHO responsible for? I experienced the same thing in the last class that I took that Veneficus alluded to; people who will never, EVER need the skills and knowledge taught in ACLS being REQUIRED to take the class because of JCAHO statutes. As well, many of these people don't have the background to pick up the course content in a whopping 16 hours. Have to wonder: with the course being required for so many people (that it shouldn't be required for) was the content dumbed down just to ensure a good passing rate so that it would remain the standard?
 
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