From the Guidelines
Starting a vasopressin drip may be harmful in patients with specific clinical conditions where its vasoconstrictive effects can exacerbate underlying diseases, such as coronary artery disease, peripheral vascular disease, or end-stage renal disease. According to the Surviving Sepsis Campaign guidelines 1, vasopressin should be used with caution and as an addition to norepinephrine, rather than as a first-line vasopressor. The guidelines recommend against using low-dose vasopressin as the single initial vasopressor for treatment of sepsis-induced hypotension, and suggest that vasopressin doses higher than 0.03–0.04 units/minute should be reserved for salvage therapy 1.
Some of the situations where starting a vasopressin drip may be harmful include:
- Patients with coronary artery disease or acute coronary syndrome, as vasopressin can cause coronary vasoconstriction, potentially worsening myocardial ischemia and precipitating infarction
- Patients with peripheral vascular disease, as vasopressin's potent vasoconstrictive effects can critically reduce blood flow to already compromised extremities, potentially leading to tissue necrosis or limb ischemia
- Patients with end-stage renal disease or acute kidney injury, as vasopressin may further compromise renal perfusion
- Patients with seizure disorders, as vasopressin may lower the seizure threshold
- Hyponatremic patients, due to vasopressin's antidiuretic effects that can worsen hyponatremia
- Pregnant women, as vasopressin can reduce uterine blood flow and potentially harm the fetus
The use of vasopressin should be carefully considered and monitored in these high-risk patients, with careful titration of the dose and close monitoring for signs of tissue ischemia, cardiac events, or electrolyte disturbances. The recommended dose of vasopressin is up to 0.03 U/min, and it should be added to norepinephrine with the intent of raising mean arterial pressure to target, or decreasing norepinephrine dosage 1.
From the FDA Drug Label
Vasopressin injection is contraindicated in patients with known allergy or hypersensitivity to 8-L-arginine vasopressin or chlorobutanol. Can worsen cardiac function The most common adverse reactions include decreased cardiac output, bradycardia, tachyarrhythmias, hyponatremia and ischemia (coronary, mesenteric, skin, digital).
Starting a vasopressin drip may be harmful in the following situations:
- Known allergy or hypersensitivity to 8-L-arginine vasopressin or chlorobutanol 2
- Cardiac function that may be worsened by vasopressin 2
- Patients at risk of decreased cardiac output, bradycardia, tachyarrhythmias, hyponatremia, or ischemia (coronary, mesenteric, skin, digital) 2
From the Research
Situations where starting vasopressin drip may be harmful
- Excessive vasoconstriction, organ ischemia, hyperglycemia, hyperlactatemia, tachycardia, and tachyarrhythmias are potential adverse effects of vasopressors, including vasopressin 3
- Vasopressin may not be beneficial in all cases of septic shock, and its use should be considered on a case-by-case basis 4
- Peripheral administration of vasopressors, including vasopressin, carries a risk of tissue injury and necrosis if extravasated, although this risk may be lower than previously thought 5
- The use of vasopressin in cardiogenic shock is not well established, and its effects on mortality are unclear, although one study suggested a potential benefit 6
- The use of vasopressin in patients with acute kidney injury is not well established, and its effects on renal function are unclear, although one study suggested that it may be safe and potentially beneficial 7
- Certain patient populations, such as those with bradycardia, may not benefit from vasopressin and may require alternative treatments, such as dopamine 3
- The concomitant use of other vasoactive drugs, such as corticosteroids, may affect the efficacy and safety of vasopressin 4