Hemodynamic Management with Vasopressin for Cardiovascular Surgery

Abstract

Background and Objectives: Vasopressin increases blood pressure through aquaporin-2-mediated water retention and is useful for managing hemodynamics after surgery. However, even after decades of study, clear clinical guidelines on doses and ideal use cases after cardiovascular surgery remain unclear. Here, the existing literature is synthesized on vasopressin use for cardiac surgeries and coupled with real-world clinical experience to outline a clearer clinical path for vasopressin use. Materials and Methods: Literature from 1966 to the present was searched, and information on surgical outcomes for cardiovascular surgery was extracted. Clinicians from the University of Tsukuba with extensive vasopressin experience in pediatric cardiovascular patients were consulted for general use guidelines. Results: Vasopressin response after cardiovascular surgery is multifaceted, and low-power trials, plus conflicting study reports, generally render it as a secondary choice behind norepinephrine. Clinical experience indicates that low doses of 0.2-0.3 mU/kg/min with constant blood pressure and oxygen monitoring for response are required. Although sole use is not recommended, vasopressin may aid in controlling hemodynamics when given with other volemic or osmolal drugs. Conclusions: Vasopressin may work in a select population of first-line non-responders, but relevant response factors remain unanalyzed and clear guidelines for use remain unestablished. Future, large-scale studies are needed to delineate temporal and demographic characteristics that affect response to vasopressin for the purpose of managing post-surgical capillary leakage and hemodynamics.

Keywords: arginine vasopressin; cardiovascular; epinephrine; norepinephrine; vasoplegic; vasopressin.

Figure 1

Vasopressin secretion, targets, and action. Vasopressin is released on demand from the paraventricular nucleus within the hypothalamus through the pituitary gland. Roughly 10–20% is released directly into the bloodstream, while the rest is systemically released under the control of feedback mechanisms and external stimuli. Four G-protein-coupled receptors, located in smooth muscle (OXY/V1a), the pituitary gland (V1b/V3), and the kidney collection ducts (V2), respond to vasopressin by vasoconstriction, reabsorption of water, or vascular tone control through multiple mechanisms. This collectively raises vascular resistance and blood fluid volumes, increasing arterial pressure. Ang II = angiotensin II; AVP = arginine vasopressin; BP = blood pressure; CREB3L1 = CAMP responsive element binding protein 3-like 1; GABA = γ-aminobutyric acid; HPA = hypothalamic-pituitary-adrenal axis; HSP = heat shock protein; NOS = nitric oxide species; OXY = oxytocin-like receptor. Created at biorender.com.