From the Guidelines
Vasopressin is primarily used in clinical settings for vasodilatory shock, cardiac arrest, diabetes insipidus, and gastrointestinal bleeding, with recommended dosing varying by condition, such as 0.01-0.07 units/minute for vasodilatory shock, starting at 0.03 units/minute and titrating based on blood pressure response 1.
Clinical Uses of Vasopressin
The clinical uses of vasopressin include:
- Vasodilatory shock: The recommended dosing is 0.01-0.07 units/minute as a continuous IV infusion, typically starting at 0.03 units/minute and titrating based on blood pressure response 1.
- Cardiac arrest: A single 40-unit IV bolus can be administered as an alternative to epinephrine.
- Diabetes insipidus: Desmopressin (DDAVP), a synthetic analog, is preferred at 10-40 mcg intranasally daily in 1-3 divided doses, or 1-4 mcg IV/subcutaneously daily in 1-2 doses.
- Gastrointestinal bleeding: Vasopressin may be given at 0.2-0.4 units/minute IV, though terlipressin is often preferred where available 1.
Mechanism of Action and Side Effects
Vasopressin works by binding to V1 receptors on vascular smooth muscle causing vasoconstriction, and V2 receptors in the kidney's collecting ducts to increase water reabsorption. Side effects include hyponatremia, vasoconstriction leading to tissue ischemia, and cardiac effects. Regular monitoring of serum sodium, blood pressure, and tissue perfusion is essential during administration, particularly with continuous infusions 1.
Dosing Recommendations
The dosing of vasopressin should be individualized and titrated to achieve the desired clinical effect, with careful monitoring of blood pressure, serum sodium, and tissue perfusion 1. Some key points to consider when dosing vasopressin include:
- Starting with a low dose and titrating up to achieve the desired effect
- Monitoring blood pressure and serum sodium closely
- Adjusting the dose as needed to minimize side effects
- Using the lowest effective dose for the shortest duration necessary to achieve the desired clinical effect.
From the FDA Drug Label
8 USE IN SPECIFIC POPULATIONS
- 1 Pregnancy Risk Summary There are no available data on vasopressin use in pregnant women to inform a drug associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. Animal reproduction studies have not been conducted with vasopressin Clinical Considerations Dose adjustments during pregnancy and the postpartum period: Because of increased clearance of vasopressin in the second and third trimester, the dose of vasopressin may need to be increased [see DOSAGE AND ADMINISTRATION (2.2) and CLINICAL PHARMACOLOGY (12. 3)]. Maternal adverse reactions: Vasopressin may produce tonic uterine contractions that could threaten the continuation of pregnancy. 8.2 Lactation There are no data on the presence of vasopressin injection in either human or animal milk, the effects on the breastfed infant, or the effects on milk production.
- 4 Pediatric Use Safety and effectiveness of vasopressin in pediatric patients with vasodilatory shock have not been established.
- 5 Geriatric Use Clinical studies of vasopressin did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy [see WARNINGS AND PRECAUTIONS (5), ADVERSE REACTIONS (6), and CLINICAL PHARMACOLOGY (12.3)].
The clinical uses of vasopressin are not explicitly stated in the provided text, but it can be inferred that it is used for vasodilatory shock in certain populations.
- The dosing recommendations for vasopressin are mentioned to be adjusted during pregnancy and the postpartum period due to increased clearance of vasopressin in the second and third trimester.
- For elderly patients, dose selection should be cautious, usually starting at the low end of the dosing range.
- The text does not provide explicit dosing recommendations for other populations, such as pediatric patients or lactating women. 2
From the Research
Clinical Uses of Vasopressin
- Vasopressin is used in the treatment of catecholamine-requiring and catecholamine-resistant shock 3
- It is also used to control bleeding from esophageal varices due to its direct vasoconstrictor activity on splanchnic arterioles and precapillary sphincters 4
- Vasopressin has been increasingly used as an early treatment of vasopressor-refractory septic shock 5
- It is used in patients with vasodilatory shock to increase the mean arterial pressure through V1 receptors and decrease the cardiac output 6
Dosing Recommendations
- The dose of vasopressin should not exceed 0.04 U/min, as higher doses may lead to cardiac arrest 6
- The administration of vasopressin in healthy subjects has little effect, whereas in vasodilatory shock it increases the mean arterial pressure 6
- Vasopressin infusion may reduce both operation time and blood loss during shunt surgery 4
Side Effects and Complications
- Diabetes insipidus is a potential side effect of vasopressin infusion, particularly after discontinuation 3, 5
- Cardiovascular complications, such as bradycardia, are common adverse effects of vasopressin 4
- Ischaemic skin lesions and possible intestinal ischaemia are also potential side effects of vasopressin 6
Expert Consensus and Guidelines
- The Italian Society of Anesthesia and Intensive Care (SIAARTI) has established guidelines for the use of vasopressors and inotropes in critically ill patients 7
- A panel of experts has identified 29 clinical questions for the use of vasopressors and inotropes in patients with septic shock and cardiogenic shock 7
- High level of agreement exists among the panel members about the appropriateness of inotropes/vasopressors' use in patients with septic shock and cardiogenic shock 7