Effects of vasopressin on the circulation, myocardial dynamics, and left ventricular oxygen consumption in the anaesthetized dog

Dose-response of vasopressin in a rat model of asphyxial cardiac arrest

The advantage of vasopressin over epinephrine in the treatment of cardiac arrest (CA) is still being debated, and it is not clear whether a high dose of vasopressin is beneficial or detrimental during or after cardiopulmonary resuscitation (CPR) in a rat model of CA. In this study, asphyxial CA was induced in 40 male Sprague-Dawley rats. After 10 minutes of asphyxia, CPR was initiated; and the effects of different doses of vasopressin (low dose, 0.4 U/kg; medium dose, 0.8 U/kg; and high dose, 2.4 U/kg; intravenous; n = 10 in each group) and a saline control (isotonic sodium chloride solution, 1 mL, intravenous) were compared. Outcome measures included the rate of restoration of spontaneous circulation (ROSC) and changes of hemodynamic and respiratory variables after ROSC. The rates of ROSC were 1 of 10 in the saline group and 8 of 10 in each of the 3 vasopressin groups. There were no differences in mean aortic pressure or changes of respiratory function after CPR among the vasopressin groups. However, the heart rate was lower in the high-dose vasopressin group than in the low- and medium-dose groups. These findings indicate that different doses of vasopressin result in a similar outcome of CPR, with no additional benefits afforded by a high dose of vasopressin during or after CPR, in a rat model of asphyxial CA. The mechanism and physiologic significance of the relative bradycardia that occurred in the high-dose vasopressin group are currently unknown and require further investigation.

Should vasopressin replace adrenaline for endotracheal drug administration?

OBJECTIVE

Arginine vasopressin was established recently as a drug of choice in the treatment of cardiac arrest and in retractable ventricular fibrillation; however, the hemodynamic effect of vasopressin following endotracheal drug administration has not been fully elucidated. We compared the effects of endotracheally administered vasopressin vs. adrenaline on hemodynamic variables in a canine model, and we investigated whether vasopressin produces the same deleterious immediate blood pressure decrease as did endotracheal adrenaline in the canine model.

DESIGN

Prospective controlled study.

SETTING

Animal laboratory in Tel-Aviv University, Israel.

SUBJECTS

Five adult mongrel dogs weighing 6.5-20 kg.

INTERVENTIONS

Dogs were anesthetized; each dog was intubated orally, and both femoral arteries were cannulated for the measurement of arterial pressure and for sampling blood gases. Each dog was studied four times, 1 wk apart, by using the same protocol for injection and anesthesia: endotracheal placebo (10 mL NaCl 0.9%,), endotracheal vasopressin (1 units/kg), endobronchial adrenaline (0.1 mg/kg), and endotracheal adrenaline (0.1 mg/kg). Following placebo, vasopressin, and adrenaline instillation, five forced manual ventilations were delivered with an Ambu bag. Each dog was its own control.

MEASUREMENTS AND MAIN RESULTS

Following placebo or drug administration, heart electrocardiography and arterial pressures were continuously monitored with a polygraph recorder for 1 hr. Endotracheal vasopressin produced an immediate increase of diastolic blood pressure (from 83 +/- 10 mm Hg [baseline] to 110 +/- 5 mm Hg at 1 min postinjection). This response lasted >1 hr. In contrast, both endotracheal and endobronchial administration of adrenaline produced an early and significant (p <.05) decrease in diastolic and mean blood pressures. The diastolic blood pressure increase from 85 +/- 10 mm Hg to 110 +/- 10 mm Hg took an ill-afforded 55 secs following endotracheal adrenaline. Diastolic blood pressure was significantly (p <.05) higher following vasopressin compared with adrenaline administration in both routes.

CONCLUSIONS

Vasopressin accomplishes its hemodynamic effect, particularly on diastolic blood pressure, more rapidly, vigorously, and protractedly and to a significant degree compared with both endotracheal and endobronchial adrenaline. Evaluation of the effects of endotracheal vasopressin in a closed chest cardiopulmonary resuscitation model is recommended.

Effects of vasopressin on right ventricular function in an experimental model of acute pulmonary hypertension

OBJECTIVE

Arginine vasopressin is a promising systemic vasopressor in settings such as vasodilatory shock and cardiopulmonary resuscitation. The evidence that arginine vasopressin may also have a pulmonary vasodilatory effect makes it an attractive drug for the treatment of circulatory shock secondary to right ventricular failure and pulmonary hypertension. In the present study, we evaluated the effects of arginine vasopressin on right ventricular function and ventriculovascular coupling in the setting of moderate acute pulmonary hypertension and compared these effects with those of phenylephrine.

DESIGN

Prospective laboratory investigation using an established model of acute pulmonary hypertension.

SETTING

University hospital laboratory.

SUBJECTS

Seven adult beagle dogs weighing 8-14 kg.

INTERVENTIONS

After acute instrumentation to measure right ventricular pressure and volume with the conductance technique and pulmonary artery flow and pressure with high-fidelity transducers, the stable thromboxane analogue U46619 was infused continuously to obtain stable pulmonary hypertension. Phenylephrine and arginine vasopressin were administered consecutively in continuous infusions at doses titrated to achieve a 25% increase in aortic pressure.

MEASUREMENTS AND MAIN RESULTS

Phenylephrine and arginine vasopressin both increased total pulmonary vascular resistance and arterial elastance without influencing characteristic impedance. Both drugs decreased cardiac output and stroke volume. Right ventricular hydraulic power output was reduced by arginine vasopressin but not by phenylephrine. Most importantly, arginine vasopressin caused a 31% decrease in right ventricular contractility measured as the slope of the preload recruitable stroke work relationship, whereas contractility was preserved during phenylephrine infusion.

CONCLUSIONS

In the present model, arginine vasopressin causes pulmonary vascular constriction and exerts an important negative inotropic effect on the right ventricle. These findings suggest that one should be cautious in the use of arginine vasopressin when right ventricular function is compromised.

ACLS Guidelines 2000: Focus on What’s “New” in the Pulseless Ventricular Tachycardia/Ventricular Fibrillation Algorithm

Despite the use of conventional treatment modalities, the probability of survival for patients experiencing cardiac arrest due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) remains quite poor. Therefore, the management of cardiac arrest remains a challenge. The most recent Advanced Cardiovascular Life Support (ACLS) guidelines have adopted an evidence-based approach toward the treatment of pulseless VT/VF. A number of evidence-based changes have been made in the treatment algorithms for these life-threatening arrhythmias, including the new recommendations for using vasopressin and intravenous amiodarone. This article will provide an overview of the evidence-based approach that was used in the development of the 2000 ACLS guidelines and will summarize the key trials that were used to support the inclusion of vasopressin and intravenous amiodarone in the pulseless VT/VF treatment algorithm. Additionally, dosing and administration issues for these agents will be discussed.

Hemodynamic effects of tracheal administration of vasopressin in dogs

BACKGROUND

Intravenous administration of vasopressin during cardiopulmonary resuscitation (CPR) has been shown to be more effective than optimal doses of epinephrine. Earlier studies had been performed on a porcine model, but pigs produce lysine vasopressin hormone, while humans and dogs do not. This study was designed to compare the effects of tracheal vasopressin with those of NaCl 0.9% (placebo) on haemodynamic variables in a dog model.

METHODS

Five dogs were allocated to receive either vasopressin 1.2 U/kg or placebo (10 ml of NaCl 0.9%) via the tracheal route after being anesthetized and ventilated. Haemodynamic variables were determined and arterial blood gases were measured.

RESULTS

All animals of the vasopressin group demonstrated a significant increase of the systolic (from 135+/-7 to 165+/-6 mmHg, P<0.05), diastolic (from 85+/-10 to 110+/-10 mmHg, P<0.05) and mean blood pressure (from 98.5+/-3 to 142.2+/-5, P<0.05). Blood pressure rose rapidly and lasted for more than an hour (plateau effect). Heart rate decreased significantly following vasopressin (from 54+/-9 to 40+/-5 beats per min, P<0.05) but not in the placebo group. These changes were not demonstrated with placebo injection.

CONCLUSION

Tracheal administration of vasopressin was followed by significantly higher diastolic, systolic and mean blood pressures in the vasopressin group compared with the placebo group. Blood gases remained unchanged in both groups. Vasopressin administered via the trachea may be an acceptable alternative for vasopressor administration during CPR, when intravenous access is delayed or not available, however, further investigation is necessary.

Innovative pharmacologic approaches to cardiopulmonary resuscitation

The survival rate of patients undergoing cardiopulmonary resuscitation is 5 to 15%. New cardiopulmonary resuscitation treatment approaches under investigation include the use of vasopressin as a vasopressor, amiodarone for the treatment of ventricular tachyarrhythmias, and adenosine antagonists (i.e., theophylline) for bradyasystolic rhythms. More innovative approaches include the use of thyroid hormone and endothelin.

Synthetic 8-ornithine-vasopressin, a clinically used vasoconstrictor, causes cardiac effects mainly via changes in coronary flow

BACKGROUND

8-ornithine-vasopressin (ornipressin, POR-8) is used as a potent peripheral vasoconstrictor mainly in combination with local anaesthetics. Because ornipressin causes vasoconstriction, any myocardial depressive effects could be caused indirectly by reduced myocardial perfusion secondary to coronary vasoconstriction, or directly by effects on myocardial tissue.

METHODS

On isolated guinea pig hearts, we compared direct effects of ornipressin by perfusion at constant flow with indirect effects by perfusion at constant pressure by Langendorff technique. Ornipressin concentrations tested were 0.05, 0.1, 0.25, 0.5 and 1.0 IU/L (1 International Unit (IU) ornipressin = 2.8 micrograms)

RESULTS

Coronary flow decreased significantly (P < 0.001) in concentration-dependent manner with ornipressin at constant pressure while AV conduction time and percentage O2 extraction (%O2E) increased and heart rate (HR), systolic left ventricular pressure (LVP) and myocardial O2 consumption (MVO2) decreased. Coronary perfusion pressure increased significantly with increasing ornipressin at constant coronary flow while HR and AV time were unchanged and LVP decreased only at the higher concentrations. At an identical or slightly reduced HR LVP product (RPP), MVO2 increased up to 27 +/- 6% at 1.0 IU/L ornipressin during constant flow perfusion.

CONCLUSION

An increase in %O2E coupled with a decrease in coronary flow at constant pressure is consistent with myocardial depression secondary to reduced tissue perfusion. These ornipressin-induced effects are not evident at constant coronary flow except for a small but direct myocardial depressant effect on LVP at higher concentrations. The increase of MVO2 at constant flow, despite equal or even reduced work, is described as Gregg's phenomenon and it is probably due to an increase in coronary perfusion pressure during coronary vasoconstriction. Even though extrapolation of our results in humans is questionable, the current indication for use of ornipressin as vasoconstrictor may need to be reconsidered, especially in patients with reduced coronary reserve.

Cardiovascular function during the postresuscitation phase after cardiac arrest in pigs: a comparison of epinephrine versus vasopressin

OBJECTIVE

The administration of vasopressin during cardiopulmonary resuscitation (CPR) provides significantly more vital organ blood flow when compared with epinephrine during cardiac arrest in pigs. The effects of this potent vasoconstrictor on postresuscitation cardiovascular function remain unknown. The purpose of this study was to compare the effects of vasopressin and epinephrine on cardiovascular function in the postresuscitation phase after CPR.

DESIGN

Prospective, randomized, experimental study.

SETTING

University research laboratory.

SUBJECTS

Domestic pigs, 12 to 14 wks of age.

INTERVENTIONS

Sixteen pigs were randomly allocated to receive either 0.045 mg/kg of epinephrine or 0.4 U/kg of vasopressin after 4 mins of cardiac arrest.

MEASUREMENTS AND MAIN RESULTS

Hemodynamics, left ventricular contractility, and myocardial blood flow were measured for an interval of 240 mins after successful CPR. Differences between animals treated with epinephrine vs. vasopressin were most pronounced 15 mins after restoration of spontaneous circulation. At this time, mean aortic pressure was 64 +/- 6 (SEM) mm Hg in the epinephrine group and 84 +/- 6 mm Hg (p < .05) in the vasopressin group. Systemic vascular resistance was 1285 +/- 72 dyne.sec/cm5 in the epinephrine group and 2314 +/- 130 dyne.sec/cm5 (p < .001) in the vasopressin group. Cardiac index was 140 +/- 9 mL/min/kg in animals treated with epinephrine and 99 +/- 9 mL/min/kg (p < .01) in animals treated with vasopressin. Myocardial contractility (dp/ dtmax/P) was 52.8 +/- 3.4/sec with epinephrine as compared with 36.3 +/- 2.9 sec-1 (p < .01) with vasopressin. Left ventricular epicardial blood flow was 241 +/- 35 mL/min/100 g with epinephrine and 142 +/- 22 mL/min/100 g (p < .05) with vasopressin. Four hours after CPR, no significant differences were observed between groups.

CONCLUSIONS

In the early postresuscitation phase, vasopressin provided higher systemic blood pressures and there was a reversible depressant effect on myocardial function when compared with epinephrine. Overall cardiovascular function was not irreversibly or critically impaired after the administration of vasopressin in this pig model of cardiac arrest.

Cardiovascular effects of angiotensin II and vasopressin in intact awake rats

1. In this study we evaluated, in intact awake rats, the effects of angiotensin II (AII) and vasopressin (AVP) on venous tone to explain their different hemodynamic effects. 2. Cardiac index (CI) was measured by thermodilution. AII and AVP were infused at the doses adjusted to increase mean arterial pressure 25, 50 and 70% above baseline. Lower doses of AVP than AII were necessary to increase mean arterial pressure at the same levels. 3. To study whether the different effects of AII and AVP on CI may be explained by their different actions on the venous system, changes in venous tone were evaluated by measuring mean circulatory filling pressure (MCFP) and determining the pressure gradient for venous return (PGVR). 4. AVP induced a decrease in CI from 32.5 +/- 2.2 to 23.1 +/- 1.7 and 15.4 +/- 0.8 ml/min/100 g (P < 0.01) with the second and third level of increase in afterload respectively, whereas AII at the same levels of afterload decreased CI from 34.8 +/- 1.3 to 28.3 +/- 2.3 and 23.4 +/- 1.7 ml/min/100 g (P < 0.01). Furthermore, the rise in total peripheral resistances (TPR) was greater with AVP than with AII at the highest level of afterload (P < 0.05). Heart rate significantly decreased more in the animals infused with AVP than with AII. 5. There were no changes in MCFP and PGVR with either AII or AVP. 6. These results indicate that in intact awake rats the larger fall in CI induced by AVP can not be explained only by a greater decrease in HR since at highest levels of afterload AVP decreased SV.(ABSTRACT TRUNCATED AT 250 WORDS)

Attenuation of vasopressin-mediated coronary constriction and myocardial depression in the hypoxic heart

To investigate the ability of arginine vasopressin (AVP) to compete with metabolic vasodilatory factors in the coronary circulation, we examined the coronary vascular and myocardial effects of AVP in isolated working rat hearts during normoxic and hypoxic perfusion. In normoxic hearts, AVP treatment (777 +/- 67 pg/ml) reduced coronary flow by 38.4 +/- 2.6%. Myocardial function was also significantly decreased by AVP whereas efficiency significantly increased. In contrast, the same dose of AVP administered to hypoxic hearts resulted in substantially smaller effects on coronary flow (-11.5 +/- 2.8%), myocardial function, and efficiency. In hearts treated first with AVP and then with hypoxia, the greater degree of coronary vasodilation compared with that observed in hearts treated with hypoxia alone also indicated an antagonizing effect of hypoxia on AVP-mediated coronary constriction. It was also noted that the hypoxia treatment alone resulted in reductions of O2 supply and consumption identical to those produced by AVP treatment during normoxia. However, hypoxia was associated with a significantly greater effect on myocardial function and, in contrast to the effect of AVP, a marked reduction in efficiency. The rate of lactate release was greater during hypoxia alone (2.07 +/- 0.08 mumol/min) than with AVP treatment during normoxia (0.76 +/- 0.05 mumol/min). These results indicate that the effect of AVP on the coronary vessels, as well as its effect on the myocardium, is significantly attenuated during hypoxia. In addition, AVP-constricted vessels appear to retain considerable vasodilatory reserve despite evidence of ischemic conditions. Thus, although the effects of AVP resemble ischemia, the increased efficiency and the relatively small effect of AVP on contractile function, as well as the preserved vasodilatory reserve, suggest otherwise. A physiological explanation for these observations is proposed wherein the constricting effects of AVP modulate the effects of autoregulatory factors such that blood flow requirements are minimized while allowing preservation of adequate blood flow for vital tissue function.

Vasopressin induced myocardial depression in neurally mediated and not due to impaired coronary blood flow

The mechanism of the cardiodepressant effect of vasopressin was studied by measuring simultaneously myocardial contractile force and coronary blood flow (with tracer microspheres) in anaesthetized open-chest rabbits. Lysine-vasopressin administered at two dose levels (10 and 100 mu kg-1 infused in 2 min with a maintenance dose of 2 mu kg-1 min-1 between these two loading doses) to a group of 6 rabbits caused dose-dependent myocardial depression and also severely decreased coronary blood flow in a dose-dependent manner. Blood pressure remained almost unchanged but heart rate, cardiac output and total peripheral conductance were also decreased dose-dependently. In another group of 6 rabbits treated in the same way with lysine-vasopressin, darodipine (PY 108-068, 30 and 100 micrograms kg-1) was infused intravenously. It reversed the vasopressin-induced coronary constriction and cardiodepression. The high dose of vasopressin brought back cardiac depression but did not reduce coronary blood flow below baseline values. Myocardial depression could therefore not be adequately explained by the changes in coronary blood flow. In a further group of rabbits which had been subjected to cervical vagotomy and beta-adrenoceptor blockade (propranolol 1 mg kg-1 i.v.) before the experiment, vasopressin still caused coronary constriction which was reversed by darodipine, but had no effect on myocardial contractile force and heart rate. The cardiodepressant effect of vasopressin can thus be explained fully by effects on the autonomic nervous system which are reversed by lowering blood pressure, whereas the severe reduction of coronary flow did not contribute to the vasopressin-induced myocardial depression.

Effect of vasopressin on phasic coronary blood flow

The effects of vasopressin on the coronary circulation have been studied with regard to its general hemodynamic effects. Aortic blood pressure (BP), left ventricular pressure (LVP), aortic blood flow (AoBF), and circumflex blood flow (CBF), were measured in 12 open-chest dogs, under control conditions and during vasopressin infusion (25 mU/kg/min). During vasopressin infusion, the mean aortic blood pressure (MBP) was increased from 104 +/- 23 mm Hg to 161 +/- 23 mm diastolic blood pressure (DBP) was more increased (+55%) than the systolic blood pressure (SBP) (+40%). AoBF was decreased from 2.169 +/- 0.408 l/min to 1.118 +/- 0.303 l/min; and the heart rate was decreased by 18%. The total combined left ventricular power did not change significantly. The increase in total peripheral resistance (TPR) (+200%) was the main change in impedance spectrum. The mean circumflex coronary blood flow (MCBF) was decreased from 48 +/- 8.6 ml/min to 33.4 +/- 9.7 ml/min. This decrease was more important in the diastolic circumflex blood flow (DCBF) (-33%) than in the systolic one (-0.8%). The diastolic pressure time index (DPTI) was more increased than the systolic pressure time index (SPTI). The DPTI/SPTI ratio was increased from 0.91 to 1.3. Long diastoles, induced by vagus nerve stimulation, have permitted to characterise the relationship between pressure and coronary blood flow during diastole. This relationship was linear under basal condition, and during vasopressin perfusion. This made it possible to determine the critical closing pressure (Pf0), and the coronary conductance (the slope of the regression curve). Vasopressin induced an increase in Pf0, from 33.7 +/- 95 to 77.4 +/- 16.07 mm Hg (p less than 0.001), and a decrease in coronary conductance, from 0.8 +/- 0.32 to 0.5 +/- 0.1 ml/min/mm Hg. The effect of an acute change in perfusion pressure on the coronary flow, under control conditions and during vasopressin infusion was studied by opening a large arteriovenous fistula. Unclamping of the fistula, under control conditions, allowed to realize an acute fall in DBP from 82.5 +/- 6.36 to 35.5 +/- 9.19 mm Hg, and in DCBF, from 58.5 +/- 9.2 to 20 +/- 9.8 ml/min. During vasopressin infusion, a similar fall in perfusion pressure lead to a zero diastolic circumflex blood flow, for a diastolic aortic blood pressure of 56 +/- 12 mm Hg. However, vasopressin did not affect the delayed active coronary vasodilatation.

Cardiac function and central circulation in lysine-vasopressin treatment of experimental burns

Anesthetized piglets were subjected to a standardized full thickness skin burn, covering one third of the body surface area, and given fluid treatment. One group was also submitted to early excision of the burned area 5 h after the burn and another group was excised and given lysine-vasopressin by continuous infusion. In both the excised groups there was earlier circulatory restitution compared with the conservatively treated animals. After 24 h, cardiac function was best in the pigs treated with vasopressin and excision. The mechanisms by which vasopressin treatment and excision might have favourable circulatory effects in burn treatment are discussed.

Triglycyl-lysine-vasopressin or lysine-vasopressin in early excision of burns. An experimental study comparing the effects on blood loss, hemodynamics and renal function

Twelve piglets were submitted to a third degree burn covering one third of total body surface area under general anesthesia. Fluid treatment was given in amounts corresponding to 2.4 ml/kg/% burn/24 h, and hemodynamics and renal function were monitored for 24 h. Regional blood flows were determined with the aid of the radioactive microsphere technique before burn, 5 and 24 h after burn respectively. One group was treated with triglycyl-lysine-vasopressin (TGLVP) as bolus injections and the other with lysine-vasopressin (LVP) in infusion. Both groups were submitted to excision of the burned tissues after 5 h. Total blood loss was 39 +/- 9 g in the TGLVP group and 51 +/- 7 g in the LVP group (n.s.). TGLVP changed the distribution of cardiac output (CO) more than LVP did, leading to smaller blood flows to the splanchnic organs, skin and carcass while the perfusion of the brain, heart, liver and kidneys was similar after 5 h. The burn caused a 30% decrease of CO in both groups. After the first TGLVP injection there was a small further decrease in CO but after excision there were similar recoveries of CO in both groups. After 24 h the CO redistribution remained during LVP infusion, but those effects had almost vanished in the TGLVP group. Total diuresis and the glomerular filtration rate tended to be larger during LVP treatment but there was no significant difference in serum creatinine after 24 h. Thus both drugs decrease blood loss during early excision and they seem to have similar effects on circulation and renal function.(ABSTRACT TRUNCATED AT 250 WORDS)