Vasopressin Infusion: Indications and Dosing Guidelines
Vasopressin is indicated to increase blood pressure in adults with vasodilatory shock who remain hypotensive despite fluids and catecholamines, with a recommended dose of 0.01-0.07 units/minute for septic shock and 0.03-0.1 units/minute for post-cardiotomy shock. 1
Primary Indications
- Vasopressin is FDA-approved for increasing blood pressure in adults with vasodilatory shock who remain hypotensive despite fluids and catecholamines 1
- It should be used as an adjunctive agent to norepinephrine, not as initial monotherapy in septic shock 2, 3
- Vasopressin can be added to norepinephrine with the intent of either raising mean arterial pressure (MAP) or decreasing norepinephrine dosage 4
Dosing Guidelines
Septic Shock
- Standard dose: 0.01-0.07 units/minute when added to norepinephrine 2, 1
- Typical starting dose: 0.01-0.03 units/minute 3, 5
- Vasopressin can be initiated when norepinephrine doses of 5-15 μg/minute or more are required 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) 4, 3
Post-Cardiotomy Shock
Administration Protocol
- Dilute 20 units/mL multiple dose vial contents with normal saline (0.9% sodium chloride) or 5% dextrose in water (D5W) to either 0.1 units/mL or 1 unit/mL for intravenous administration 1
- Discard unused diluted solution after 18 hours at room temperature or 24 hours under refrigeration 1
- Administration requires central venous access 2, 5
- Arterial catheter placement is recommended for all patients requiring vasopressors as soon as practical 4, 3
- Target MAP is typically 65 mmHg 4, 5
Clinical Considerations and Monitoring
- Adequate fluid resuscitation should precede or accompany vasopressor therapy (minimum of 30 mL/kg of crystalloids) 4, 5
- Measuring cardiac output is desirable when using pure vasopressors like vasopressin to maintain normal or elevated flow 3, 5
- Continuous arterial blood pressure monitoring is essential for patients receiving vasopressors 2, 5
Potential Adverse Effects
- Decreased cardiac output, bradycardia, tachyarrhythmias 1, 6
- Hyponatremia 1
- Ischemia (coronary, mesenteric, skin, digital) 1, 6
- Reversible diabetes insipidus 1
- Gastrointestinal hypoperfusion 7
Drug Interactions
- Pressor effects of catecholamines and vasopressin are expected to be additive 1
- Indomethacin may prolong effects of vasopressin 1
- Co-administration of ganglionic blockers or drugs causing SIADH may increase the pressor response 1
- Co-administration of drugs causing diabetes insipidus may decrease the pressor response 1