AVP: All Vasopressin Podcast

Vasopressin and Septic Shock

Vasopressin is commonly used as an adjunctive agent in the treatment of septic shock. It is suggested in the surviving sepsis campaign guidelines as a second-line agent to be added to norepinephrine when patients have inadequate mean arterial pressure levels. The timing of vasopressin initiation is typically recommended when the norepinephrine dose is in the range of 0.25 to 0.5 mcg/kg/min. For individual patients, it may be considered earlier, possibly around a dose of 10 to 15 mcg/min. Vasopressin has a unique mechanism of action compared to catecholamines, augmenting G-coupled receptors and causing vasoconstriction. However, it has relative sparing of pulmonary arteries and afferent renal arterial, resulting in less pulmonary vasoconstriction and increased glomerular filtration pressure. Vasopressin is known to have certain adverse effects, such as digital ischemia and potential hyperbilirubinemia at higher doses. There is a phenomenon of variable hemodynamic response to vasopressin, with about 45% of patients exhibiting a positive response. However, predicting who will respond favorably to vasopressin remains challenging. Factors like lower lactate concentrations have been associated with better response, but further research is needed to identify specific predictors. Vasopressin does not generally require dose adjustments based on weight or BMI. Echo findings may have an impact on the decision to use vasopressin, with patients showing LV systolic dysfunction potentially having a lower response rate. While vasopressin is commonly used in septic shock, the importance of vasopressin compared to corticosteroids is not well-established. There is currently no robust data directly comparing vasopressin to corticosteroids for the treatment of septic shock.