Vasopressin in haemorrhagic shock - Vasopressin vs Fluid

Wed Aug 1 02:24:55 BST 2007

Ivan,
I'm still figuring it out as i go along, patient to patient. what you say
makes sense. but it isnt the design of the vitris study, which gives fluids
first, then randomises the patients to either vasopressin or placebo
in the situation of  non responsiveness to fluid. so you're not going to get
an answer to your question when the study gets published.
there is an interesting device under manufacture which seems to follow the
philosophy you're advocating. the details are accesible here.
http://mtlweb.mit.edu/researchgroups/mems/docs/2006/mems_37.pdf
anecdotally,two weeks back i got a ruptured spleen, who came in late, in non
responsive shock, after prepping and draping, intubation, i gave a bolus of
vasopressin with the skin incision, in the hopes that his blood pressure
wouldnt crash further when his peritoneum was opened. unfortunately he went
into asystolic arrest before the bleeding could be controlled.
with regards to jacobs point wrt the porcine model, i was given to
understand that as long as the pigs are splenectomised prior to the
experiment being carried out ( since porcine spleens tend to contract and
autotransfuse in the face of bleeding) the findings and blood pressure
readings are close to and applicable to human beings.
sincerely,
rangraj
On 8/1/07, IVAN HRONEK <ih7 at msn.com> wrote:
>
> Rangraj and everybody,
>
> do you use Vasopressin in the trauma pts. in hemorr. shock and if so, do
> you use it prior to control of hemorrhage following the delayed
> resuscititation philosophy with no or low fluids.It would seem to be the
> way to go if one wishes to keep the BP marginal. With fluids you will
> actually increase the cardiac output but not even increase  O2 delivery
> anyway - both things you really don't want if you go by the delayed
> resuscitation philosophy. Vasonstriction achieved by Vasopressin should
> potentially also decrease the uncontrolled bleeding. Ivan Hronek MDChief,
> Critical Care & Trauma AnesthesiaSFMC Gas, Inc.St. Francis Medical
> Center3630 E. Imperial HighwayLynwood, CA 90262 Cell: 310 487-3288Pager: 310
> 636-6020
>
>
>
> > Date: Mon, 30 Jul 2007 16:10:18 +0530> From: rangraj at gmail.com> To:
> trauma-list at trauma.org> Subject: Re: Vasopressin in haemorrhagic shock -
> Vasopressin vs Fluid> > just used it today. 40 kg woman with splenomegaly
> and bleeding esophageal> varices for splenectomy and devasc. started oozing,
> had 11/2 blood volumes> relaced, got cold, CVP 20, BP dropping (80/50),
> resonding to dopamine but> fairly high doses required,, started a background
> infusion of vasopressin,> BP came up,dopamine came down, and the oozing
> switched off, enabling the> surgeon to see what he was doing. pretty cool.>
> rangraj> > On 7/30/07, IVAN HRONEK <ih7 at msn.com> wrote:> >> > More to the
> discussion - I am sure there are lurkers who have used> > Vasopressin in
> hemorr. shock ..right ?> >> > I am also trying to invite Drs. Roth and
> Stadlbauer to join this> > discussion group by including their email and
> their letters to the editor> > for the list members here...> > Anesth Analg
> 2006;102:1908(c) 2006 International Anesthesia Research> > Societydoi:
> 10.1213/01.ANE.0000215135.44887.7E> >> >> > LETTER TO THE EDITOR> > Bolus
> Vasopressin During Hemorrhagic Shock? Jonathan V. Roth, MD> > Department of
> Anesthesiology; Albert Einstein Medical Center; Philadelphia,> > PA;
> rothj at einstein.edu> > To the Editor:> > In their case report, Sharma and
> Setlur (1) report two hypotensive> > patients whose blood pressures were
> poorly responsive to catecholamines but> > then increased in response to
> infusions of 0.04 U/min of vasopressin. One> > patient's arterial blood
> pressure started increasing after 1 h of> > vasopressin; the other's began
> increasing after 30 min. There was no mention> > of either patient receiving
> an initial bolus dose of vasopressin. The> > accompanying editorial
> recognized that there are limited clinical data on> > timing and dosage of
> vasopressin administration (2). These articles support> > the idea that
> vasopressin has a valuable role, although controlled studies> > are needed
> and dosing guidelines need to be established (2).> > With many medications,
> a bolus is often given before an infusion to obtain> > a more rapid
> response. However, because of the potential side effects and> > lack of
> supporting data, one may hesitate to administer a bolus of> > vasopressin.
> For this reason, I present some of my experience with bolus> > vasopressin.>
> > During open abdominal aortic aneurysm surgery, patients will sometimes> >
> develop hypotension not responsive to catecholamines during bowel> >
> retraction. I will then administer 1 or 2 boluses of vasopressin, 0.4 U,>
> > by IV push. This is typically sufficient to treat the hypotension. I have>
> > not observed any evidence of myocardial ischemia by electrocardiogram> >
> monitoring. The dose of 0.4 U is 2 orders of magnitude less than the 40 U>
> > recommended in Advanced Cardiac Life Support protocols.> > Admittedly,
> this is a very different situation than hemorrhagic shock.> > However, my
> experience provides some support to the safety of 0.4 U IV> > push
> vasopressin in a patient population who is at increased risk for> >
> myocardial ischemia. I present this not as a recommendation but as a> >
> starting point for adequate and well-controlled studies to establish the> >
> safety and efficacy of bolus vasopressin for rapid correction of> >
> hypotension.> > References> >> >> > Sharma RM, Setlur R. Vasopressin in
> hemorrhagic shock. Anesth Analg> > 2005;101:833–4.[Abstract/Free Full Text]>
> > Stadlbauer KH, Volker W, Krismer AC, et al. Vasopressin during> >
> uncontrolled hemorrhagic shock: less bleeding below the diaphragm, more> >
> perfusion above. Anesth Analg 2005;101:830–2.[Free Full Text]Anesth Analg> >
> 2006;102:1908(c) 2006 International Anesthesia Research Societydoi:
> 10.1213> > /01.ANE.0000215143.26601.E8> >> >> > LETTER TO THE EDITOR> >
> Bolus Vasopressin During Hemorrhagic Shock? Karl H. Stadlbauer, MD, Volker>
> > Wenzel, MD, Anette C. Krismer, MD, Wolfgang G. Voelckel, MD, and Karl H.>
> > Lindner, MD> > Department of Anesthesiology and Critical Care Medicine;
> Innsbruck Medical> > University; Innsbruck, Austria;
> karl-heinz.stadlbauer at uibk.ac.at> > 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.Ivan Hronek MDChief, Critical Care> > &
> Trauma AnesthesiaSFMC Gas, Inc.St. Francis Medical Center3630 E.> >
> Imperial HighwayLynwood, CA 90262 Cell: 310 487-3288> > Pager: 310 636-6020>
> >> > > Date: Tue, 24 Jul 2007 13:22:10 +0530> From: rangraj at gmail.com>
> To:> > trauma-list at trauma.org> Subject: Re: Vasopressin in haemorrhagic
> shock -> > Vasopressin vs Fluid> > this an article I'd written a few years
> back on the> > subject, with its> accompanying editorial, and a trial which
> is being> > carried out to look into> the subject. I feel that vasopressin
> has certain> > advantages in patients who> dont respond to catecholamines
> after adequate> > volume resuscitation, the> important ones being an ability
> to act in severe> > metabolic acidosis, and an> apparent ability to resore
> the baroreceptor> > reflexes.that being said, it is> certainly not a
> substitute for achieving> > hemostasis> rangraj> On 7/24/07, Jacob Scholtz <
> jacob.scholz at gmail.com>> > wrote:> >> > After having read the thread about
> massive transfusion> > protocols I> > received> > an e-mail with the
> following article:> >> >> > Vasopressin improves survival in a porcine model
> of abdominal vascular> >> > injury> > Critical Care 2007, 11:R81 doi:
> 10.1186/cc59772007, 11:R81 doi:> > 10.1186> > /cc5977> > The authors
> conclude:> > "Vasopressin, but not fluid> > resuscitation or saline placebo,
> ensured> > short-term survival in this> > vascular injury model with
> uncontrolled> > haemorrhagic shock in sedated> > pigs."> >> > They were pigs
> and they were not transfused, but what does the> > list think> > about
> vasopressin, maybe in conjunction with transfusion, in> > human> >
> haemorrhagic shock?> >> > Jacob> > --> > trauma-list : TRAUMA.ORG>> > > To
> change your settings or unsubscribe visit:> >> >
> http://www.trauma.org/index.php?/community/> >> > > > -- > Lt Col Rangraj>
> > Setlur> Associate Professor> Department of Anaesthesiology and Critical> >
> Care> Armed Forces Medical College> Pune> India--> > trauma-list :
> TRAUMA.ORG> > To change your settings or unsubscribe visit:> >
> http://www.trauma.org/index.php?/community/> >> > > > -- > Lt Col Rangraj
> Setlur> Associate Professor> Department of Anaesthesiology and Critical
> Care> Armed Forces Medical College> Pune> India> --> trauma-list :
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-- 
Lt Col Rangraj Setlur
Associate Professor
Department of Anaesthesiology and Critical Care
Armed Forces Medical College
Pune
India