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LETTER TO THE EDITOR

The Use of Vasopressin Bolus to Treat Refractory Hypotension Secondary to Reperfusion During Orthotopic Liver Transplantation

Department of Anesthesiology; Albert Einstein Medical Center; Philadelphia, PA; rothj{at}einstein.edu

To the Editor:

Vasopressin infusions have been used to treat hypotension in a variety of situations (1–4). However, without an initial loading dose, there may be a significant delay until the medication has an effect (1,5). There are little data to suggest a safe and effective bolus dose of vasopressin. The following case provides additional support for the safe use of bolus vasopressin.

A 53-yr-old, 82 kg, male underwent orthotopic liver transplantation for hepatitis C cirrhosis and hepatocellular carcinoma. Surgery was uneventful up to the time of reperfusion, including systolic blood pressure (95–110 mm Hg), pulmonary arterial pressure (30/14 mm Hg), and central venous pressure (10 mm Hg). The patient received one gram of calcium chloride 1 min before reperfusion.

Within 1–2 min after liver reperfusion, his arterial blood pressure decreased to 55/30 mm Hg, pulmonary arterial pressure increased to 38/19 mm Hg, and central venous pressure increased to 12 mm Hg. An additional gram of calcium and increasing bolus doses of norepinephrine as large as 160 µg plus a norepinephrine infusion of 16 µg/min failed to accomplish more than a transient increase in systolic blood pressure to 81 mm Hg. Two bolus doses of vasopressin, 0.4 U each, increased the systolic blood pressure to 98 mm Hg, which was sustained for 3–5 min. Another vasopressin bolus of 0.4 U vasopressin was administered, and the patient was placed on vasopressin infusion at 4 U/h. The norepinephrine and vasopressin infusions were maintained for the duration of the surgery and into the early postoperative period. Pulmonary arterial pressure and central venous pressure returned to baseline within 15–30 min.

The patient did not become acidotic. Urine output was satisfactory during and after the procedure. There were no adverse cardiac, neurologic, hepatic, renal, or pulmonary events. The graft functioned well and the patient was discharged home on the fifth postoperative day.

This report provides support for the use of vasopressin bolus and infusion in treating hypotension refractory to catecholamines resulting from the reperfusion syndrome during liver transplantation. The vasopressin dose of 0.4 U is 2 orders of magnitude less than that recommended in advanced cardiac life support protocols (40 U) (6) and may not be the optimal bolus dose. Well-controlled studies need to be conducted to establish the indications, safety, and efficacy of bolus vasopressin for rapid correction of hypotension.

REFERENCES

1. Sharma RM, Setlur R. Vasopressin in hemorrhagic shock. Anesth Analg 2005;101:833–4.[Abstract/Free Full Text]
2. Raedler C, Voelckel WG, Wenzel V, et al. Treatment of uncontrolled hemorrhagic shock after liver trauma: fatal effects of fluid resuscitation versus improved outcome after vasopressin. Anesth Analg 2004;98:1759–61.[Abstract/Free Full Text]
3. Voelckel WG, Raedler C, Wenzel V, et al. Arginine vasopressin, but not epinephrine, improves survival in uncontrolled hemorrhagic shock after liver trauma in pigs. Crit Care Med 2003;31:1160–5.[Web of Science][Medline]
4. Morales D, Madigan J, Cullinane S, et al. Reversal by vasopressin of intractable hypotension in the late phase of hemorrhagic shock. Circulation 1999;100:226–9.[Abstract/Free Full Text]
5. Roth JV. Bolus vasopressin during hemorrhagic shock? Anesth Analg 2006;102.
6. ACLS Provider Manual. Dallas: American Heart Association, 2003.

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