Can exogenous vasopressin analogue be given to patients with severe sepsis with collapsing circulation?

คำตอบ

Vasopressin is a potent vasopressor for improving organ perfusion during septic shock. Although it is released in response to stress or shock states, a relative deficiency of vasopressin has been found in prolonged vasodilatory shock, such as seen in severe sepsis. In this circumstance, exogenous vasopressin has marked vasopressor effects, even at doses that would not affect blood pressure in healthy individuals. Recent findings provide the rationale for the use of vasopressin in the treatment of septic shock. However, doses of vasopressin should not exceed 0.04 U/min, as higher doses have been shown to produce myocardial ischaemia and cardiac arrest. In the UK, vasopressin is often used to restore mean arterial pressure (MAP) in septic patients when high doses of conventional inotropes and vasopressors have failed. Results from the recent Vasopressin and Septic Shock Trial (VASST) suggest that low-dose vasopressin added to conventional vasopressors may be more effective than supplementary norepinephrine in reducing mortality, but only in less severe septic shock. Interestingly, the patients who received vasopressin were given more dobutamine and milrinone than the norepinephrine group. Terlipressin is a long-acting (half-life 6 hr) synthetic analog of vasopressin (available in some countries) which as been shown to have beneficial haemodynamic effects in patients with septic shock who are unresponsive to conventional vasopressors. At dose of 1-2 mg IV in patient with septic shock, substantially increases mean arterial pressure (MAP), urine output, systemic vascular resistance index, pulmonary vascular resistance index, and left and right ventricular stroke work index while decreasing heart rate, cardiac output, lactate, and oxygen delivery and consumption index. The use of terlipressin in this setting requires further clarification of its dose requirements, side-effects, and efficacy.

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