Arginine vasopressin during cardiopulmonary resuscitation: Laboratory evidence, clinical experience and recommendations, and a view to the future

Abstract

When stimulating adult pigs with ventricular fibrillation or postcountershock pulseless electrical activity for cardiopulmonary resuscitation, vasopressin improved vital organ blood flow, cerebral oxygen delivery, ability to be resuscitated, and neurologic recovery better than epinephrine. In pediatric preparations with asphyxia, epinephrine was superior to vasopressin, whereas in both pediatric pigs with ventricular fibrillation and adult porcine models with asphyxia, combinations of vasopressin and epinephrine proved to be highly effective. This may suggest that a different efficiency of vasopressors in pediatric vs. adult preparations and different effects of dysrhythmic vs. asphyxial cardiac arrest on vasopressor efficiency may be of significant importance. Whether these theories can be extrapolated to humans is unknown at this time. In patients who experienced out-of-hospital ventricular fibrillation, a larger proportion of patients treated with vasopressin survived 24 hrs compared with patients treated with epinephrine; during in-hospital cardiopulmonary resuscitation, comparable short-term survival was found in groups treated with either vasopressin or epinephrine. Currently, a large trial comprising patients who experience out-of-hospital cardiac arrest and who are treated with vasopressin vs. epinephrine is ongoing in Germany, Austria, and Switzerland. The new cardiopulmonary resuscitation guidelines of both the American Heart Association and the European Resuscitation Council consider 40 units of vasopressin intravenously and 1 mg of epinephrine intravenously equally effective for the treatment of adult patients with ventricular fibrillation; however, because of a lack of clinical data, no recommendation for vasopressin has been made for adult patients with asystole and pulseless electrical activity or for pediatric patients.

ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death

“…Beta blockers may be preferred for ACSs if not already being taken. For pharmacological hemodynamic support during cardiac arrest management, vasopressin has been suggested as an alternative to epinephrine (344), but the evidence for superiority is not clearly established. Responses to nontachyarrhythmic cardiac arrest largely focus on control of metabolic and transient factors that may precipitate bradyarrhythmic events or pulseless electrical activity (Fig.…”

Successful biphasic transthoracic defibrillation of a dog with prolonged, refractory ventricular fibrillation

“…Epinephrine and vasopressin may be used as an adjunct to defibrillation in an attempt to increase the coronary and cerebral perfusion pressure. 11 This dog received these recommended interventions and medications for CPR including monophasic defibrillation shocks at the recommended initial energy dose of 2-5 J/kg increasing to the maximal energy dose of 10 J/kg for patients 415 kg. 10 All attempts to reestablish normal circulatory function were unsuccessful until sinus rhythm was restored with a single biphasic shock.…”

Update on cardiopulmonary resuscitation and emergency cardiovascular care guidelines

“…It has the theoretical advantage over epinephrine of increasing oxygen delivery to vital organs without increasing oxygen consumption and worsening ischemia. [62][63][64][65][66] In cardiac arrest, the lack of perfusion causes anaerobic metabolism and lactate accumulation, quickly resulting in acidosis. In this hypoxic and acidotic state, adrenergic receptors become less sensitive to the vasoconstrictive effects of epinephrine and other catecholamines.…”

“…56,57 Vasopressin continues to cause vasoconstriction in the presence of acidosis. [62][63][64][65][66] In addition, studies have shown that increased epinephrine levels after cardiac arrest are associated with increased mortality, while increased levels of vasopressin are associated with improved survival. 67 A number of animal studies and early human trials found that the use of vasopressin in cardiac arrest improved ROSC, increased CPP, and improved neurologic outcomes.…”