Arginine-Vasopressin in severe septic vs. non-septic shock in extremely low birth weight infants with acute renal failure

Abstract

Background: Recent clinical investigations have demonstrated that arginine-vasopressin (AVP) may be a valuable alternative or adjunct to common pressor agents in various forms of shock (1, 2). Although, typically septic shock is characterized by AVP deficiency and pressor hypersensitivity to the exogenous hormone, AVP has also been successfully employed in other shock forms that are usually not characterised by AVP deficiency. Aim: To assess the efficacy of AVP as a pressor adjunct to norepinephrine and epinephrine in severe septic vs. non-septic shock in extremely low birth weight infants (ELBW) with acute renal failure (urine output: <0.5ml/kg/h). Patients and Methods: Assessment of AVP therapy as a rescue therapy in three ELBW infants (mean birth weight: 600±30 grams) with severe septic shock and acute renal failure and three ELBW infants (mean birth weight: 770±110grams) with severe non-septic shock and acute renal failure. Main outcome measure was restoration of mean arterial blood pressure (MAP) with reversal of acute renal failure, and survival at discharge. Results: In the group with severe septic shock two hours after starting AVP (dosage:0.04–0.4 U/kg/h) a rise in MAP from 31.7±9.5 to 39.7±19.1mmHg was seen; urine output increased to 9.7±11.5ml/h, and a slight decrease in serum lactate from 9.6±6.7 mmol/l to 8.9±6.2 was noticed. In the group with severe non-septic shock, MAP increased from 25±5 to 38.7±8.3mmHg within 2h of AVP medication (dosage: 0.04–0.4U/kg/h); urine output increased to 5.4±3.2ml/h. Serum lactate moderately increased from 14.3±5.1 to 15.2±6.2 mmol/l. In the non-septic group cardiac and renal changes were only transient and did not impact on the poor prognosis. Mortality rate was 1/3 in the sepsis group vs. 3/3 in the non-septic group. Conclusion: This is the first report on AVP in severe hypotensive shock in ELBW infants. AVP appears to be effective in restoring MAP and subsequent reversal of acute renal failure. Maintenance of adequate and sustained tissue perfusion appears to be dependent on the underlying cause of hypotension. Although AVP seems to be an effective rescue therapy in severe septic shock in ELBW infants further evaluation in controlled clinical trials is warranted.