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  1. Pharmacology

    1. Vasopressin is a peptide hormone that is synthesized in the hypothalamus. The primary stimuli for endogenous physiologic release are hyperosmolality, hypotension, and hypovolemia. It is used in the critical care setting for severe catecholamine-resistant vasodilator shock, in which case it acts as a potent vasoconstrictor. Conditions in which vasopressin has been used include septic shock, postcardiotomy shock, and hemorrhagic shock. There are insufficient and conflicting human and animal data to recommend its use routinely to manage shock from poisoning. Further data are needed to define its risks, benefits, and optimum dose. Increases in arterial pressure should be evident within the first hour. Its serum half-life is less than 15 minutes.

  2. Indications

    1. Note: Vasopressin should not be used as a first-line agent to treat hypotension. It is used as add-on therapy to treat severe vasodilator hypotension that is unresponsive or refractory to one or more adrenergic agents (eg, high-dose dopamine, epinephrine, norepinephrine, phenylephrine). There are limited case reports in the medical literature in which vasopressin was used for drug overdose.

    2. As a means to reduce adrenergic agent requirements during the treatment of vasodilator hypotension.

  3. Contraindications

    1. Vasopressin infusion should be discontinued if there is a decrease in the cardiac index and/or stroke volume. Note: Serious consideration should be given to monitoring cardiac indexes invasively via a pulmonary artery catheter to titrate hemodynamic effects and dosing.

    2. Use with extreme caution if there is evidence of decreased cardiac output despite adequate intravascular volume or evidence of cardiogenic shock.

    3. Vasopressin should be used cautiously in treating a patient with an overdose of an agent that has myocardial depressant effects (eg, calcium channel blockers, beta blockers).

  4. Adverse effects

    1. Negative inotropic effect. Vasopressin may result in a decrease in the cardiac index. This may be attributed to an increase in systemic vascular resistance and afterload on a depressed myocardium or may be related in part to a compensatory decrease in the heart rate. Dobutamine and milrinone have been used in conjunction with vasopressin in attempts to attenuate this negative inotropic effect.

    2. Ischemia (especially at doses > 0.05 U/min)

      1. Cardiac arrest has been reported at doses above 0.05 U/min.

      2. Ischemic skin lesions of the distal extremities and trunk and lingual regions.

      3. Mesenteric ischemia and hepatitis may occur.

    3. Thrombocytopenia

    4. Use in pregnancy. FDA Category B (See Introduction in Section III). There are no reports linking the use of vasopressin with congenital defects. Vasopressin and the related synthetic agents desmopressin and lypressin have been used during pregnancy to treat diabetes insipidus.

  5. Dosage and method of administration

    1. Intravenous infusion at 0.01–0.04 U/min. Vasopressin should be diluted with normal saline or 5% dextrose in water to a final concentration of 0.1–1 U/mL.

      Doses higher than 0.04 U/min are not recommended and may be associated with a greater incidence of adverse effects (see above). Administration through central venous access is recommended to minimize the risk for extravasation. Local skin necrosis has occurred when vasopressin was infused through a peripheral venous catheter.

    2. Once an adequate blood pressure is achieved and stabilized, ...

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