Note: Units of measure vary by indication and age (ie, milliunits/kg/hour, units/kg/hour, milliunits/kg/minute, units/kg/minute; units/minute, units/hour); extra precautions should be taken.
Cardiac surgery (complex procedure; eg, Norwood; arterial switch); post-bypass: Limited data available: Continuous IV infusion: Mean reported dose range: 0.3 to 0.5 milliunits/kg/minute, titrated to hemodynamic goals (Alten 2012; Burton 2011). Dosing based on experience in 37 neonates (n=19 in vasopressin group) which showed a mean infusion rate: 0.3 milliunits/kg/minute (range: 0.08 to 1 milliunit/kg/minute) was associated with decreased catecholamine use and significant reduction in fluid resuscitation during first 24 hours after surgery compared to the control group (Alten 2012); a retrospective report of 28 neonates with refractory hemodynamic instability after Norwood palliation showed improvement in urine output, SBP, and pH markers with vasopressin at a mean infusion rate of 0.5 milliunits/kg/minute (Burton 2011). Note: Hyponatremia reported frequently; monitor serum Na (Alten 2012; Davalos 2013).
Hypotension (initial therapy): Very limited data available (Rios 2014): ELBW neonates (GA ≤30 weeks): Continuous IV infusion: Reported range: 0.17 to 0.67 milliunits/kg/minute (0.01 to 0.04 units/kg/hour); dosing initiated at low end of range and titrated at 20 minute intervals in 0.17 milliunits/kg/minute (0.01 units/kg/hour) increments. Dosing based on a prospective, randomized, double-blind trial comparing vasopressin and dopamine as initial therapy in 20 hypotensive ELBW neonates (vasopressin treatment group, n=10; mean GA: 25.7 weeks; PNA: <24 hours; mean birth weight: 640 g) with a control group of 50 normotensive ELBW neonates; primary efficacy outcomes were similar in both treatment groups; other findings showed that subjects in the vasopressin group received significantly fewer surfactant doses and had a lower mean PaCO2; and unlike the dopamine group, tachycardia was not observed in the vasopressin group (Rios 2015).
Persistent pulmonary hypertension of the newborn (PPHN), refractory: Very limited data available: GA ≥37 weeks: Continuous IV infusion: Initial: 0.1 milliunits/kg/minute, increase in 0.1 milliunits/kg/minute increments every hour as needed for clinical response to a maximum dose of 1.2 milliunits/kg/minute; dosing based on a case series in 10 neonates (GA ≥37 weeks; birth weight ≥2.2 kg) which showed significant improvement in oxygenation index, blood pressure, and urine output and a reduction in iNO dose (Mohamed 2014)
Shock; vasodilatory with refractory hypotension unresponsive to fluid resuscitation and exogenous catecholamines: Limited data available; dosing regimens and efficacy results variable: Continuous IV infusion: 0.17 to 10 milliunits/kg/minute (0.01 to 0.6 units/kg/hour) have been used; doses were initiated at the lower end of the range and titrated to effect in most studies. Dosing based on retrospective reviews and case reports that have shown increases in arterial blood pressure and urine output and also allowed for dosage reductions of additional vasopressors (Bidegain 2010; Brierley 2009; Choong 2008; Ikegami 2010; Meyer 2008).
Note: Units of measure vary by indication and age (ie, milliunits/kg/hour, units/kg/hour, milliunits/kg/minute, units/kg/minute; units/minute, units/hour); extra precautions should be taken.
Diabetes insipidus: Note: Highly variable dosage; titrate dosage based upon serum and urine sodium and osmolality in addition to fluid balance and urine output. Children and Adolescents: IM, SubQ: 2.5 to 10 units 2 to 4 times daily (Gal 2007).
Central diabetes insipidus: Limited data available: Infants, Children, and Adolescents: Continuous IV infusion: Initial: 0.5 milliunits/kg/hour; titrate upward in 0.5 milliunits/kg/hour increments at approximately 10-minute intervals to target urine output (suggested output target: <2 mL/kg/hour) (Sperling 2014; Wise-Faberowski 2004); infusion rates up to 10 milliunits/kg/hour have been reported (Alharfi 2013). Note: Use in conjunction with fluid therapy, monitor urine output and specific gravity, serum and urine electrolytes (primarily Na), and plasma osmolality.
Cadaveric organ donations (hormone replacement therapy): Limited data available (Nakagawa/NATCO Guidelines 2008): Infants, Children, and Adolescents: Continuous IV infusion: Initial: 0.5 to 1 milliunits/kg/hour; titrate dose to maintain targeted urine output. In a retrospective case-controlled study (n=34, age: 8.2 ± 6.2 years), a mean dose of 41 milliunits/kg/hour was reported with a range of 0.2 milliunits/kg/hour to 150 milliunits/kg/hour (Katz 2000).
GI hemorrhage: Limited data available: Children and Adolescents: Continuous IV infusion: Initial: 2 to 5 milliunits/kg/minute; titrate dose as needed; maximum dose: 10 milliunits/kg/minute (Gal 2007; Tuggle 1988); usual adult dosing range is 0.2 to 0.4 units/minute up to a maximum rate of 0.8 units/minute (AASLD [Garcia-Tsao 2007]). Note: Higher doses have not been associated with greater efficacy but have been associated with increased risk of complications (Tuggle 1988).
Pulseless arrest, ventricular fibrillation, ventricular tachycardia: Limited data available: Infants, Children, and Adolescents: IV: 0.4 units/kg as a single dose after traditional resuscitation methods and at least two doses of epinephrine have been administered. Note: Due to insufficient evidence, no formal recommendations for or against the routine use of vasopressin during pediatric cardiac arrest are provided (Duncan 2009; Mann 2002; PALS 2010).
Vasodilatory shock with hypotension unresponsive to fluid resuscitation and exogenous catecholamines: Limited data available; efficacy results have varied (SCCM [Dellinger 2013]): Infants, Children, and Adolescents: Continuous IV infusion: 0.17 to 8 milliunits/kg/minute (0.01 to 0.48 units/kg/hour) has been used; dosing based on retrospective reviews and case reports that have shown increases in arterial blood pressure and urine output and also allowed for dosage reductions of additional vasopressors (Brierley 2009; Choong 2008; Meyer 2008). The only double-blind, placebo-controlled trial (n=65, age: 3 to 14 years) evaluated a dose of 0.5 to 2 milliunits/kg/minute (0.03 to 0.12 units/kg/hour) at multiple centers and found no significant difference in the time to reach hemodynamic stability and a trend toward increased mortality in the vasopressin group was noted. Based on these findings, the authors did not recommend routine use of vasopressin (Choong 2009). Note: Abrupt discontinuation of infusion may result in hypotension; to discontinue, gradually taper infusion.
There are no dosage adjustments provided in the manufacturer's labeling.
There are no dosage adjustments provided in the manufacturer's labeling.
(For additional information see "Vasopressin: Drug information")
Diabetes insipidus, central (acute) (off-label use): Note: Dosage is highly variable; titrated based on serum and urine sodium and osmolality in addition to fluid balance and urine output. Vasopressin may be considered for short-term use in some neurocritical care settings due to its short duration of action (ES [Fleseriu 2016]; Murphy-Human 2010; Prete 2017). Use in neurosurgical patients is generally limited to the early postoperative period (eg, days 1 to 4); use caution in this setting to avoid overtreatment, as diabetes insipidus may spontaneously resolve or revert to syndrome of inappropriate antidiuretic hormone secretion/hyponatremia (ES [Fleseriu 2016]; Prete 2017).
SUBQ (off-label route): 5 to 10 units 2 to 3 times daily as needed (Prete 2017).
Continuous infusion: IV: Continuous infusion has not been formally evaluated in the post-neurosurgical adult. However, some clinicians may convert SUBQ requirement to an hourly continuous IV infusion rate with careful titration based on urine output (Murphy-Human 2010). Specific protocols may vary.
Septic shock and other vasodilatory shock states (adjunctive agent): Note: Considered as adjunctive use when goal mean arterial pressure (MAP) not achieved with initial catecholamine vasopressor (eg, norepinephrine) or to decrease catecholamine vasopressor dosage requirements. In general, maintain goal MAP (eg, ~65 mm Hg); consider use if patient is hypotensive or has elevated lactate (eg, ≥4 mmol/L) during or after fluid resuscitation (SCCM [Dellinger 2013]; SCCM [Evans 2021]; SCCM [Levy 2018]; SCCM [Rhodes 2017]).
Shock, sepsis:
Continuous infusion: IV: 0.03 units/minute added to norepinephrine as a fixed dose (not titrated); usual dosage range: 0.01 to 0.04 units/minute; doses >0.04 units/minute should be reserved for salvage therapy due to potential risk of ischemic complications (eg, skin, cardiac, splanchnic) (Bauer 2020; Dünser 2003; Klinzing 2003; Russell 2008; Russell 2021; SCCM [Dellinger 2013]; SCCM [Rhodes 2017]).
Discontinuation in septic shock: Multiple studies describe clinically significant hypotension when vasopressin is discontinued prior to norepinephrine. When discontinuing therapy, consider slowly tapering by 0.01 units/minute every 30 to 60 minutes to reduce the risk of hypotension; monitor MAP when discontinuing vasopressin (Bauer 2010; Bissell 2019; Jeon 2018; Manaker 2021; Musallam 2018; Sacha 2018).
Shock, post-cardiotomy: Continuous infusion: IV: Initial: 0.03 units/minute. If the target blood pressure response is not achieved, titrate up by 0.005 units/minute at 10- to 15-minute intervals (maximum dose: 0.1 units/minute). After target blood pressure has been maintained for 8 hours without the use of catecholamines, taper by 0.005 units/minute every hour as tolerated to maintain target blood pressure.
Cadaveric organ recovery (hormone replacement therapy) (off-label use): Based on limited data: Note: Use if hypotensive despite adequate fluid resuscitation, left ventricular ejection fraction <45%, low systemic vascular resistance (SVR), or if diabetes insipidus is present. Use in combination with levothyroxine (or liothyronine), methylprednisolone, and continuous insulin infusion (goal blood glucose: 120 to 180 mg/dL) (Kotloff 2015; Zaroff 2002).
IV: Initial: 0.01 to 0.04 units/minute (Kotloff 2015); some experts recommend a bolus of 1 unit followed by 0.01 to 0.1 units/minute titrated to a SVR of 800 to 1,200 dynes-sec/cm5 (usual dose: 0.01 to 0.04 units/minute) (Garrity 2019).
Gastroesophageal variceal hemorrhage (alternative agent) (off-label use): Note: Other therapies (eg, octreotide) may be preferred (AASLD [Garcia-Tsao 2017]).
Continuous infusion: IV: Initial: 0.2 to 0.4 units/minute, may titrate dose as needed to a maximum dose of 0.8 units/minute; maximum duration is 24 hours at highest effective dose (to reduce incidence of adverse effects). Administer IV nitroglycerin concurrently to prevent ischemic complications; monitor closely for signs/symptoms of ischemia (myocardial, peripheral, bowel) (AASLD [Garcia-Tsao 2017]).
There are no dosage adjustments provided in the manufacturer's labeling.
There are no dosage adjustments provided in the manufacturer's labeling.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Intravenous:
Vasostrict: 0.2 units/mL (100 mL); 0.4 units/mL (100 mL); 20 units/mL (1 mL)
Vasostrict: 20 units/mL (10 mL) [contains chlorobutanol (chlorobutol)]
Generic: 20 units/mL (1 mL)
Solution, Intravenous [preservative free]:
Generic: 20 units/mL (1 mL)
Yes
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Injection:
Generic: 20 units/mL (1 mL, 2 mL, 5 mL)
Parenteral:
IM, SubQ: Administer without further dilution.
Continuous IV infusion: Dilute prior to administration. Infusion through central line is strongly recommended.
Vesicant; ensure proper needle or catheter placement prior to and during infusion; avoid extravasation. If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity. Initiate phentolamine (or alternative antidote) (see Management of Drug Extravasations for more details).
SUBQ (off-label route): Administer without further dilution.
Continuous IV infusion: Dilute 1 mL and 10 mL vials prior to administration; premixed vials (20 units/100 mL and 40 units/100 mL) requiring no further dilution are also available for single use. Infusion through central line is recommended.
Vesicant; ensure proper needle or catheter placement prior to and during infusion; avoid extravasation.
Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity. Initiate topical nitroglycerin. Apply dry, warm compresses (based on mechanism of extravasation injury proximal to the injection site) (Reynolds 2014).
Nitroglycerin (topical): Nitroglycerin topical 2% ointment (based on mechanism of extravasation injury): Apply a 1-inch strip to the site of ischemia; may repeat every 8 hours as necessary (Reynolds 2014).
Store intact vials between 2°C and 8°C (36°F and 46°F). Do not freeze.
May also remove intact vials from refrigeration and store at 20°C to 25°C (68°F to 77°F) for up to 12 months or manufacturer expiration date, whichever is earlier (indicate date of removal on the vial or note the manufacturer expiration date, whichever is earlier). After initial entry into the 10 mL vial, opened vial must be refrigerated; discard 30 days after first puncture. Discard unused diluted solution (in D5W or NS) after 18 hours at room temperature or 24 hours under refrigeration.
Pitressin (synthetic): Treatment of diabetes insipidus (FDA approved in pediatric patients [age not specified] and adults)
Vasostrict: To increase blood pressure in patients with vasodilatory shock (eg, postcardiotomy or sepsis) who remain hypotensive despite fluids and catecholamines (FDA approved in adults)
Has also been used as an adjunct in the treatment of acute massive GI hemorrhage; treatment of pulseless arrest, ventricular fibrillation or tachycardia, and asystole/pulseless electrical activity; systemic hypotension and persistent pulmonary hypertension in neonates; and cadaveric organ donation
Note: Although abdominal roentgenography and postoperative abdominal distention (prevention/treatment) are included as FDA approved uses in the manufacturer's prescribing information, there is insufficient evidence to recommend the use of vasopressin for these indications. A data review determined that the evidence was insufficient to recommend the use of vasopressin in the setting of postoperative adynamic ileus following abdominal surgery (Traut 2008). Vasopressin has been removed from the adult cardiac arrest algorithm; based on the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, vasopressin offers no advantage as a substitute for epinephrine and no advantage when used in combination with epinephrine as a substitute for standard dose epinephrine in adult cardiac arrest (ventricular fibrillation [VF]/pulseless ventricular tachycardia [pVT], asystole, or pulseless electrical activity [PEA]).
PIT or Pitressin (old names sometimes used to describe vasopressin) may be confused with Pitocin
Vasopressin may be confused with desmopressin
The Institute for Safe Medication Practices (ISMP) includes this medication (IV or intraosseous administration) among its list of drugs which have a heightened risk of causing significant patient harm when used in error.
Use care when prescribing and/or administering vasopressin solutions. Close attention should be given to concentration of solution, route of administration, dose, and rate of administration (units/minute, units/kg/minute, units/kg/hour).
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
Frequency not defined:
Cardiovascular: Atrial fibrillation, bradycardia, ischemic heart disease, limb ischemia (distal), low cardiac output, right heart failure, shock (hemorrhagic)
Dermatologic: Skin lesion (ischemic)
Endocrine & metabolic: Hyponatremia
Gastrointestinal: Mesenteric ischemia
Hematologic & oncologic: Decreased platelet count, hemorrhage (intractable)
Hepatic: Increased serum bilirubin
Renal: Renal insufficiency
Postmarketing: Endocrine & metabolic: Diabetes insipidus (reversible)
Hypersensitivity to vasopressin or any component of the formulation; hypersensitivity to chlorobutanol (Vasostrict 10 mL vial only).
Concerns related to adverse effects:
• Diabetes insipidus: Reversible diabetes insipidus may occur following discontinuation of vasopressin therapy; signs/symptoms may include polyuria, dilute urine, and hypernatremia. Monitor electrolytes, fluid status, and urine output after vasopressin discontinuation. Readministration of vasopressin (or desmopressin) may be needed to correct fluid and electrolyte imbalances.
• Extravasation: Vesicant; ensure proper needle or catheter placement prior to and during infusion. Extravasation may lead to severe vasoconstriction and localized tissue necrosis; also, gangrene of extremities, tongue, and ischemic colitis. Avoid extravasation.
• Water intoxication: May cause water intoxication; early signs include drowsiness, listlessness, and headache; these should be recognized to prevent coma and seizures.
Disease-related concerns:
• Cardiovascular disease: Use with caution in patients with cardiovascular disease, including arteriosclerosis; may worsen cardiac output.
• Migraine: Use with caution in patients with a history of migraines.
• Renal impairment: Use with caution in patients with renal disease.
• Vascular disease: Use with caution in patients with vascular disease.
May cause hyponatremia; frequency not well-defined in pediatric patients and may vary based on indication. In young pediatric patients (mean age: 5.2 months; including neonates) who received a vasopressin infusion for hemodynamic instability following complex cardiac surgery, the observed incidence of hyponatremia (defined as serum Na <135 mEq/L) was statistically higher in the vasopressin group than the control (48% vs 17%, p=0.004) and the decrease in serum sodium concentration was significantly greater (9.9 mEq/L vs 7.5 mEq/L, p=0.009); it was also observed that the decrease in the serum Na was more rapid in the vasopressin group (Davalos 2013). With other uses in pediatric patients, hyponatremia has not been characterized; monitor fluid balance, serum Na and urine output closely.
None known.
Alpha-/Beta-Agonists (Direct-Acting): May enhance the hypertensive effect of Vasopressin. The effect of other hemodynamic parameters may also be enhanced. Risk C: Monitor therapy
Desmopressin: Hyponatremia-Associated Agents may enhance the hyponatremic effect of Desmopressin. Risk C: Monitor therapy
Drugs Suspected of Causing Diabetes Insipidus: May diminish the therapeutic effect of Vasopressin. Specifically, the pressor and antidiuretic hormone effects of vasopressin may be decreased. Risk C: Monitor therapy
Drugs Suspected of Causing SIADH: May enhance the therapeutic effect of Vasopressin. Specifically, the pressor and antidiuretic effects of vasopressin may be increased. Risk C: Monitor therapy
Indomethacin: May enhance the therapeutic effect of Vasopressin. Specifically, vasopressin effects on cardiac index and systemic vascular resistance may be enhanced. Risk C: Monitor therapy
Mecamylamine: May enhance the therapeutic effect of Vasopressin. Specifically, the effect of vasopressin on mean arterial blood pressure may be increased. Risk C: Monitor therapy
Vasopressin may produce tonic uterine contractions. Due to pregnancy-induced physiologic changes, vasopressin clearance may be increased in the second and third trimesters; dose adjustment may be needed. Clearance returns to normal within 2 weeks postpartum.
Specific monitoring determined by indication and may include: Blood pressure, heart rate, fluid intake and output, urine specific gravity, urine and serum osmolality; serum and urine sodium: Hemoglobin and hematocrit (GI bleeding). Consult individual institutional policies and procedures.
Vasopressin concentration:
Basal: <4 pg/mL
Water deprivation: 10 pg/mL
Shock: 100 to 1,000 pg/mL (biphasic response)
Vasopressin stimulates a family of arginine vasopressin (AVP) receptors, oxytocin receptors, and purinergic receptors (Russell 2011). Vasopressin, at therapeutic doses used for vasodilatory shock, stimulates the AVPR1a (or V1) receptor and increases systemic vascular resistance and mean arterial blood pressure; in response to these effects, a decrease in heart rate and cardiac output may be seen. When the AVPR2 (or V2) receptor is stimulated, cyclic adenosine monophosphate (cAMP) increases which in turn increases water permeability at the renal tubule resulting in decreased urine volume and increased osmolality. Vasopressin, at pressor doses, also causes smooth muscle contraction in the GI tract by stimulating muscular V1 receptors and release of prolactin and ACTH via AVPR1b (or V3) receptors.
Onset of action:
Antidiuretic: Peak effect: 1 to 2 hours (Murphy-Human 2010).
Vasopressor effect: IV: Rapid with peak effect occurring within 15 minutes of initiation of continuous IV infusion.
Duration: SUBQ: Antidiuretic: 2 to 8 hours; IV: Vasopressor effect: Within 20 minutes after IV infusion terminated.
Absorption: None from GI tract, destroyed by trypsin in GI tract, must be administered parenterally.
Distribution: Vd: 140 mL/kg.
Protein binding: None.
Metabolism: Hepatic, renal (inactive metabolites).
Half-life elimination: IV, SubQ: 10 to 20 minutes (apparent half-life: ≤10 minutes).
Excretion: SUBQ: Urine (5% as unchanged drug) after 4 hours; IV: Urine (~6% as unchanged drug).
Solution (Vasopressin Intravenous)
20 units/mL (per mL): $189.65 - $189.66
Solution (Vasostrict Intravenous)
20 units/mL (per mL): $254.85
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