Are individuals with sepsis deficient in vasopressin (antidiuretic hormone)?

From the Guidelines

In sepsis, many patients do develop relative vasopressin deficiency, which contributes to refractory hypotension. The normal physiological response to low blood pressure should include sustained vasopressin release, but this mechanism becomes impaired in sepsis 1. This understanding has led to the use of exogenous vasopressin as an adjunctive vasopressor in septic shock, particularly in patients who remain hypotensive despite adequate fluid resuscitation and norepinephrine administration 1. Some key points to consider in the management of sepsis include:

• The use of norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg 1
• The addition of vasopressin (0.03 U/min) to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose, but not as the initial vasopressor 1
• The potential benefits of using vasopressin to restore vascular tone through V1 receptors on vascular smooth muscle and reduce the dose requirements for catecholamine vasopressors, potentially limiting their adverse effects 1. It is essential to prioritize the management of sepsis based on the most recent and highest quality evidence, focusing on morbidity, mortality, and quality of life as the primary outcomes 1.

From the FDA Drug Label

14 CLINICAL STUDIES Increases in systolic and mean blood pressure following administration of vasopressin were observed in 7 studies in septic shock and 8 in post-cardiotomy vasodilatory shock.

The FDA drug label does not answer the question.

From the Research

Vasopressin Deficiency in Sepsis

• Vasopressin deficiency has been identified as a contributor to the vasodilation of septic shock, with studies showing that patients with septic shock have lower plasma vasopressin levels compared to those with cardiogenic shock 2.
• The administration of exogenous vasopressin has been shown to increase arterial pressure and improve peripheral vasoconstriction in patients with septic shock, suggesting that vasopressin deficiency plays a role in the hypotension of septic shock 2.
• The use of arginine-vasopressin (AVP) as a therapy for septic shock has been studied, with some trials showing beneficial effects on hemodynamic variables and others showing no significant benefit 3, 4.

Clinical Use of Vasopressin in Sepsis

• Current guidelines recommend norepinephrine as the first-line vasopressor in septic shock, with vasopressin and its analogues considered second-line agents 5, 6.
• The use of vasopressin in septic shock is generally reserved for patients who are refractory to norepinephrine or who have a high risk of renal failure 6, 4.
• The optimal dosing and timing of vasopressin administration in septic shock are not well established, with some studies suggesting that low-dose continuous infusion may be beneficial 3, 4.

Key Findings

• Vasopressin deficiency is a common feature of septic shock, and exogenous administration of vasopressin can improve hemodynamic variables 2.
• Norepinephrine is currently recommended as the first-line vasopressor in septic shock, with vasopressin considered a second-line agent 5, 6.
• Further research is needed to determine the optimal use of vasopressin in septic shock, including the dosing, timing, and patient selection 3, 4.