When is vasopressin recommended for use?

Vasopressin Use Recommendations

Vasopressin is recommended as a second-line vasopressor in septic shock, added to norepinephrine at a dose of 0.03 units/minute to either raise mean arterial pressure (MAP) to target or decrease norepinephrine dosage when initial vasopressor therapy is insufficient. 1

Primary Indications for Vasopressin

• Vasopressin is indicated primarily for refractory septic shock when norepinephrine alone fails to achieve target MAP of 65 mmHg 2, 1
• It should not be used as the first-line vasopressor but added to norepinephrine when needed 1, 3
• Doses higher than 0.03-0.04 units/minute should be reserved for salvage therapy (when other vasopressors have failed to achieve target MAP) 2, 1
• Vasopressin can be beneficial in vasodilatory shock states with relative vasopressin deficiency 4, 5

Dosing Protocol

• Standard dose is 0.03 units/minute when added to norepinephrine 1
• Safe dose range is 0.01-0.04 units/minute; higher doses may lead to adverse vasoconstriction-mediated events 1, 5
• Initiation is typically triggered by:
  • Norepinephrine dose (commonly 0.25-0.50 μg/kg/min) 3
  • Duration of norepinephrine administration (often after >2-6 hours) 3
  • Combination of both dose and duration factors 3

Clinical Benefits

• Increases systemic vascular resistance and arterial blood pressure 5, 6
• Reduces requirements for catecholamine vasopressors 3, 6
• May improve urine output due to increased glomerular filtration rate 6
• May be particularly beneficial in less severe septic shock (shown in some studies to reduce mortality compared to norepinephrine alone) 7

Administration Requirements

• Requires central venous access for administration 1
• Arterial catheter placement is recommended for all patients requiring vasopressors 2, 1
• Continuous arterial blood pressure monitoring is essential 1

Potential Adverse Effects

• Reduced cardiac output in patients with cardiac dysfunction 6
• Potential ischemia of mesenteric mucosa, skin, and myocardium 6
• Elevated hepatic transaminase and bilirubin concentrations 6
• Hyponatremia and thrombocytopenia have been reported 6
• Risk of digital or skin ischemia and non-occlusive mesenteric ischemia 3

Tapering and Discontinuation

• Tapering should be triggered by achievement of target MAP 3
• Discontinuation typically begins after the first-line vasopressor (norepinephrine) has been reduced below a predefined threshold 3
• Tapering should be progressive rather than abrupt 3

Important Considerations

• Adequate fluid resuscitation should precede or accompany vasopressor therapy 1
• Vasopressin should not be used in sepsis without shock 2
• The VASST trial showed no significant difference in 28-day mortality between vasopressin and norepinephrine in the overall population of septic shock patients (35.4% vs 39.3%, p=0.26) 7
• Vasopressin may be particularly beneficial in less severe septic shock cases 7