What is the recommended dose of vasopressin (Vasopressin) in patients with septic shock?

Recommended Dose of Vasopressin in Septic Shock

The recommended dose of vasopressin in septic shock is 0.01-0.03 units/minute, with 0.03 units/minute being the standard target dose for most patients. 1, 2

Initial Dosing and Titration

• According to the FDA drug label, the recommended starting dose for vasopressin in septic shock is 0.01 units/minute 2
• Titrate up by 0.005 units/minute at 10-15 minute intervals until target blood pressure is reached 2
• The Surviving Sepsis Campaign guidelines recommend vasopressin 0.03 units/minute as an adjunct to norepinephrine with the intent of either raising MAP or decreasing norepinephrine dosage 3
• Vasopressin is typically added when norepinephrine requirements are moderate to high and should be considered as an adjunctive agent rather than a first-line vasopressor 1

Maximum Dosing

• Doses higher than 0.03-0.04 units/minute should be reserved for salvage therapy (failure to achieve adequate MAP with other vasopressor agents) 3
• There are limited data for doses above 0.07 units/minute for septic shock, and adverse reactions are expected to increase with higher doses 2
• A 2022 study comparing 0.03 units/minute versus 0.04 units/minute found no significant difference in hemodynamic response between these two dosages, suggesting no additional benefit from the higher dose 4

Clinical Application

1. First-line therapy: Begin with norepinephrine (0.05-0.1 μg/kg/min) as the first-choice vasopressor 1
2. When to add vasopressin: Consider adding vasopressin when:
   • Target MAP (≥65 mmHg) is not achieved despite adequate fluid resuscitation
   • Norepinephrine requirements are increasing
3. Vasopressin dosing:
   • Start at 0.01 units/minute 2
   • Titrate by 0.005 units/minute every 10-15 minutes 2
   • Target dose of 0.03 units/minute 3, 1

Monitoring and Safety

• All patients requiring vasopressors should have an arterial catheter placed as soon as practical for continuous blood pressure monitoring 3, 1
• After target blood pressure has been maintained for 8 hours without catecholamines, taper vasopressin by 0.005 units/minute every hour as tolerated 2
• Monitor for potential adverse effects including digital ischemia, mesenteric ischemia, and myocardial ischemia 5
• Vasopressin response (defined as a lowering of catecholamine dose required to maintain MAP ≥65 mmHg) at 6 hours after initiation is associated with more favorable clinical outcomes 6

Important Considerations

• Ensure adequate fluid resuscitation before or during vasopressor therapy 1
• Vasopressin infusions of >0.04 units/minute may lead to adverse vasoconstriction-mediated events 7
• Vasopressin should be diluted in normal saline (0.9% sodium chloride) or 5% dextrose in water prior to intravenous administration 2
• Discard unused diluted solution after 18 hours at room temperature or 24 hours under refrigeration 2

By following these evidence-based recommendations for vasopressin dosing in septic shock, clinicians can optimize hemodynamic support while minimizing potential adverse effects.