Vasopressin: a review of clinical indications
Article information
Vasopressin is frequently utilized in emergency settings for its ability to elevate blood pressure in patients experiencing hypotension. Although vasopressin is typically used as a secondary agent to sustain blood pressure in septic shock patients, it has a variety of other uses due to its broad physiological effects.
Vasopressin achieves vasoconstriction by activating the V1a receptor on vascular smooth muscle cells [1]. Additionally, it interacts with V1b and V2 receptors [1]. The V1b receptors are found in the anterior pituitary gland and pancreas, where they stimulate the secretion of cortisol and insulin [1]. V2 receptors are located on the basolateral surface of renal tubular cells within the collecting ducts, where they promote the recruitment of aquaporin 2 and increase the permeability of the epithelial membrane to water [1]. In the body, vasopressin secretion is regulated by plasma osmolality and blood volume and pressure [1]. Vasopressin has numerous indications in the emergency department as listed in Table 1.
Indications for vasopressin use
SEPTIC SHOCK
In septic shock, as well as other states of critical illness, patients tend to be vasopressin depleted [1]. The Surviving Sepsis Campaign 2021 Guidelines recommend using norepinephrine as the first-line agent over other vasopressors for adults with septic shock [2]. For such patients on norepinephrine with inadequate mean arterial pressure level, they suggest adding vasopressin instead of escalating the dose of norepinephrine [2]. A systematic review comparing vasopressin to norepinephrine as first-line vasopressors in septic shock revealed that patients in the vasopressin group had lower odds of renal replacement therapy [3]. That review also included the VANISH trial, which demonstrated similar findings; patients treated with vasopressin as opposed to norepinephrine had higher urine output, reduced serum creatinine, and a decreased need for dialysis following fluid resuscitation [3,4]. These benefits may be explained by vasopressin-induced vasoconstriction of renal efferent arterioles, which enhances the glomerular filtration rate [5]. Vasopressin had no effect on the blood pressure of healthy (not vasopressin depleted) individuals [1].
PULMONARY EMBOLISM
Vasopressin also shows benefits in cases of massive pulmonary embolism by raising systemic vascular resistance while simultaneously promoting pulmonary vasodilation and improving right ventricular afterload [5]. Increasing renal filtration and urine output reduces blood volume, which can be advantageous in pulmonary embolism where excess intravascular volume may be harmful and lead to worsening right ventricular failure [6].
VARICEAL BLEEDING
This medication is also widely used for managing acute variceal bleeding. It is believed to induce splanchnic arteriolar vasoconstriction, which decreases portal inflow and pressure [7]. In cirrhotic patients with variceal bleeding, those treated with vasopressin had similar efficacy and mortality to those treated with octreotide [8].
HEMORRHAGIC SHOCK DUE TO TRAUMA
Traditional teaching suggests that early administration of vasopressors in trauma may increase mortality due to elevated cardiac afterload, arrhythmias, and reduced tissue perfusion [5]. The later stages of hemorrhagic shock involve inhibition of the sympathetic response, resulting in lack of vasoconstriction, as in distributive shock due to catecholamine and/or vasopressin depletion [5]. Additionally, patients may be vasopressin depleted from continuous blood loss from the trauma itself [5]. A recent randomized controlled trial investigated whether vasopressin supplementation in trauma patients with hemorrhagic shock could reduce the need for blood transfusions [9]. Patients included in the study had received at least 6 units of packed red blood cells within 12 hours. The study found that, although continuous vasopressin infusion did not impact mortality, it was linked to a reduced need for blood product transfusion. The authors theorize that this may be due to increased vascular tone and promotion of platelet aggregation via V1 receptors, leading to enhanced hemostasis [5,9].
CONTRAINDICATIONS
Despite its various uses, vasopressin should be avoided in specific scenarios. It induces splanchnic vasoconstriction, which can be detrimental for patients with mesenteric ischemia or those at risk of anastomotic breakdown [10]. It may also lead to cardiac and limb ischemia due to its vasoconstrictive properties [10]. These adverse effects were predominantly observed in patients receiving doses exceeding 0.04 units/min and when administered with other catecholamine vasopressors [10]. Vasopressin, unlike most other vasopressors, commonly is administered at a fixed dose of 0.03 units/min rather than being titrated to response [2]. In trials with vasopressin doses up to 0.06 units/min, negative side effects were observed [2]. Vasopressin should not be used peripherally as there is no antidote in the setting of extravasation [11]. The contraindications mentioned above are summarized in Table 2.
Side effects and contraindications for vasopressin use
Although traditionally regarded as a secondary vasopressor, particularly in septic shock, vasopressin has a range of other indications. Using vasopressin as a primary vasopressor in certain conditions may improve patient survival and outcomes.
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Author contributions
Conceptualization: all authors; Investigation: all authors; Methodology: all authors; Project administration: all authors; Resources: all authors; Supervision: all authors; Visualization: all authors; Writing–original draft: GO; Writing–review & editing: all authors. All authors read and approved the final manuscript.
Conflicts of interest
The authors have no conflicts of interest to declare.
Funding
The authors received no financial support for this study.
Data availability
Data sharing is not applicable as no new data were created or analyzed in this study.
References
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Capsule Summary
What is already known
Vasopressin is a widely used medication in emergency departments for hypotensive patients, most commonly used as a second-line option.
What is new in the current study
Vasopressin has numerous indications where it should be considered for first-line use, such as pulmonary embolism, acute variceal bleeding, and acute kidney injury in septic shock.