In this episode, I’ll discuss 5 changes to the ACLS guidelines that hospital pharmacists should know about.
The ACLS guidelines have been updated for 2025 and published at cpr.heart.org, and updated algorithms can be found at this link. Some notable changes are:
1. Vasopressin has been downgraded from a weak recommendation to a recommendation of “no benefit” with the authors now saying: Vasopressin alone or vasopressin in combination with epinephrine offers no advantage as a substitute for epinephrine for adult patients in cardiac arrest.
If you still have vials of vasopressin in your code cart that get wasted due to expiration, this update should provide the justification needed to remove them from the code cart.
2. In the section on polymorphic ventricular tachycardia, the word “unstable” was removed from the recommendations. This was done to avoid confusion – polymorphic ventricular tachycardia is always unstable, but by placing the word unstable in the guidelines, this could be taken to imply that there is such a thing as stable torsades.
3. Inhaled beta-2 agonists have been given a recommendation of having “no benefit” in the treatment of cardiac arrest from hyperkalemia.
There was no mention of using inhaled beta-2 agonists for hyperkalemia in the 2020 guidelines, and the guideline authors in general recommend against any interventions that might interfere with providing high quality CPR.
4. A weak recommendation was made that says: There is insufficient evidence to recommend a specific vasopressor to treat low blood pressure in adult patients after cardiac arrest.
Post arrest care recommendations were last updated in 2015, and there was no mention of what vasopressor to use then. The guidelines authors are emphasizing that there is still not enough data to support choosing a specifc vasopressor for all post-arrest patients and clinicians will need to make this decision based on patient specific factors.
5. A recommendation of no benefit was given for the routine use seizure prophylaxis in adult patients who do not follow commands after ROSC.
This was also not addressed in the 2015 post arrest care section of the guidelines, and this recommendation can be used to avoid giving patients unnecessary antiseizure medications.
The topic in this episode is inspired by an in-depth training available to members of my Hospital Pharmacy Academy. The Hospital Pharmacy Academy is my online membership site that will teach you practical critical care and hospital pharmacy skills you can apply at the bedside so that you can become confident in your ability to save lives and improve patient outcomes. To get immediate access to this and many other resources to help in your practice, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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