Bolus Vasopressin During Hemorrhagic Shock?

Abstract

In Response: We appreciate the comments of Dr. Roth (1) regarding the use of vasopressin discussed in our recent editorial (2). We agree that an initial loading dose of arginine vasopressin may be useful to treat shock, but this depends on the dynamics of the situation. For example, we never inject a bolus dose of arginine vasopressin during vasodilatory shock (3). However, vasopressin may be quite useful in a patient with uncontrolled hemorrhagic shock and collapsing arterial blood pressure (4). Pharmacological mechanisms in normovolemic shock states are very different from those associated with shock in trauma patients with continuing massive hemorrhage (5). It is correct that some injections of a vasopressin bolus were harmful. This occurred when dosages equivalent to cardiopulmonary resuscitation dosages (40 IU) were used during routine surgical procedures. Complications were also reported when vasopressin analogues with several hours duration of action (arginine vasopressin action lasts several minutes) were administered in patients with angiotensin-converting enzyme inhibitor treatment during hypotension after induction of anesthesia (6). As Dr. Roth suggests, injecting a “mini” bolus of 0.4 IU arginine vasopressin (1% of the cardiopulmonary resuscitation dosage) to treat catecholamine-refractory hypotension during anesthesia seems to be a sound approach to increase mean arterial blood pressure sufficiently and allows careful titration as well. We also concur that prospective clinical trials need to be performed before this strategy can be widely recommended. Karl H. Stadlbauer, MD Volker Wenzel; MD Anette C. Krismer, MD Wolfgang G. Voelckel, MD Karl H. Lindner, MD Department of Anesthesiology and Critical Care Medicine Innsbruck Medical University Innsbruck, Austria [email protected]