What is the recommended dose of vasopressin (antidiuretic hormone) for various clinical indications?

Vasopressin Dosing for Clinical Indications

For vasodilatory and septic shock, vasopressin should be administered at a fixed dose of up to 0.03 U/min as an adjunctive agent to norepinephrine, not as a single initial vasopressor. 1

Vasopressin in Shock Management

Vasodilatory/Septic Shock

• First-line therapy: Norepinephrine (0.05-0.1 μg/kg/min, titrated by 0.05-0.1 μg/kg/min every 5-15 minutes) 1
• Adjunctive vasopressin:
  • Dose: Up to 0.03 U/min (fixed dose)
  • Purpose: To raise MAP or decrease norepinephrine requirements 1
  • Safety: Doses higher than 0.04 U/min have not shown increased effectiveness and may be associated with higher adverse effects, including cardiac arrest 2

Cardiogenic Shock

• Vasopressin is not recommended without ScvO2/CO monitoring 1
• Dobutamine (2.5-20 μg/kg/min) may be added to improve cardiac output and tissue perfusion 1

Central Cranial Diabetes Insipidus

Adults

• Dosage range: 0.1 mL to 0.4 mL (10-40 mcg) of desmopressin nasal spray 0.01% daily
• Administration: Either as a single dose or divided into 2-3 doses
• Most common regimen: 0.2 mL (20 mcg) daily in two divided doses 3

Children (3 months to 12 years)

• Dosage range: 0.05 mL to 0.3 mL (5-30 mcg) daily
• Administration: Either as a single dose or divided into two doses 3

Clinical Considerations and Monitoring

Benefits of Vasopressin in Shock

• Increases mean arterial pressure (MAP) by approximately 18% 2
• Increases urine output (by approximately 79% within 4 hours) 2
• Decreases catecholamine requirements (by 33% at 4 hours, 53% at 24 hours) 2
• Particularly useful in states of "relative vasopressin deficiency" such as septic shock 4

Potential Adverse Effects

• Decreased cardiac index (approximately 11% reduction) 2
• Excessive vasoconstriction causing:
  • Myocardial ischemia
  • Mesenteric ischemia
  • Digital ischemia
  • Arrhythmias 5, 6

Special Considerations

• Elderly patients: Dose adjustment may be needed due to decreased renal function 3
• Fluid restriction should be observed with desmopressin for diabetes insipidus 3
• Monitor:
  • Blood pressure
  • Heart rate
  • Urine output
  • Skin perfusion
  • Mental status
  • Lactate clearance
  • Renal and liver function tests 1

Important Caveats

• Vasopressin should not be used as a single initial vasopressor in shock 1
• The VASST trial showed no significant difference in 28-day mortality between vasopressin and norepinephrine in septic shock overall, though there was a potential benefit in less severe septic shock 7
• The nasal spray pump for desmopressin can only deliver doses of 0.1 mL (10 mcg) or multiples of 0.1 mL; for other doses, the rhinal tube delivery system may be used 3
• Discard desmopressin nasal spray after 50 sprays as subsequent doses may deliver substantially less than 10 mcg 3