Early use of small-dose vasopressin for unstable hemodynamics in an acute brain injury patient refractory to catecholamine treatment: a case report

Fluid resuscitation in multiple trauma patients

PURPOSE OF REVIEW

Fluid resuscitation in trauma patients with hemorrhagic shock is controversially discussed in the literature. The coincidence of brain injury complicates management of these patients. This article summarizes the current knowledge on nonblood component fluid resuscitation and choice of fluids in patients with multiple trauma.

RECENT FINDINGS

Whereas current evidence suggests the efficacy of fluid therapy in hemorrhagic shock without active bleeding, experimental and clinical data demonstrate that aggressive volume challenge may be futile or even deleterious in the setting of uncontrolled hemorrhage. Large amounts of isotonic crystalloids may be associated with hypothermia, acidosis and inflammation. In patients with traumatic brain injury hypertonic solutions may positively influence inflammation and intracranial pressure without affecting neurologic outcome or mortality.

SUMMARY

To date no large-scale clinical studies exist to either support or refute the use of nonblood component fluid resuscitation of hemorrhagic shock in trauma patients. The optimal choice of fluid remains to be determined, but existing evidence suggests avoiding crystalloids in favor of hypertonic solutions. The role of modern, iso-oncotic colloids in the treatment of hemorrhagic shock has not yet been sufficiently defined. In patients with concomitant brain injury, arterial hypotension must be avoided and infusion of hypotonic solutions is obsolete, whereas administration of hypertonic solutions may exert beneficial effects beyond hemodynamic stabilization.

Vasopressin: Its current role in anesthetic practice

Vasopressin or antidiuretic hormone is a potent endogenous hormone, which is responsible for regulating plasma osmolality and volume. In high concentrations, it also raises blood pressure by inducing moderate vasoconstriction. It acts as a neurotransmitter in the brain to control circadian rhythm, thermoregulation and adrenocorticotropic hormone release. The therapeutic use of vasopressin has become increasingly important in the critical care environment in the management of cranial diabetes insipidus, bleeding abnormalities, esophageal variceal hemorrhage, asystolic cardiac arrest and septic shock. After 10 years of ongoing research, vasopressin has grown to a potential component as a vasopressor agent of the anesthesiologist's armamentarium in the treatment of cardiac arrest and severe shock states.

Arginine vasopressin: a promising rescue drug in the treatment of uncontrolled haemorrhagic shock

Haemorrhagic shock is one of the most frequent types of shock. If haemorrhage cannot be controlled and fluid resuscitation as well as catecholamines are insufficient to stabilize cardiovascular function, uncontrolled haemorrhagic shock occurs. Several approaches have been suggested as promising alternatives to volume resuscitation. The rationale for the use of arginine vasopressin (AVP) is the pharmacologic amplification of the neuroendocrine stress response. AVP-mediated vasoconstriction is the first physiologic step to haemostasis and shifts blood away from the bleeding site towards the heart, lungs and brain. Particularly, when uncontrolled haemorrhage is accompanied by traumatic brain injury this may help to reduce secondary neurological damage. Since AVP can prevent acute death only transiently, it must comprehensively be combined with rapid hospital admission, immediate control of haemorrhage followed by aggressive fluid resuscitation and blood transfusion. This review article summarizes current experimental and clinical evidence on the use of AVP in uncontrolled haemorrhagic shock.

Hypothalamic injury as a cause of refractory hypotension after sellar region tumor surgery

INTRODUCTION

Fluid-resistant arterial hypotension can result in hypoperfusion of the brain and other organs. Well-known causes of arterial hypotension in neurosurgical practice include cardiac failure, septic shock, adrenal insufficiency, brainstem, and cervical spinal cord damage. Fluid-resistant arterial hypotension can occur in patients with brain edema without damage to brainstem when hypothalamic nuclei suffer. This phenomenon is not a well-documented cause of hypotension.

METHODS

We prospectively investigated 15 cases with clinical syndrome of arterial hypotension in patients following surgery for sellar region tumors. These cases were taken from 1005 patients operated between May 2003 and December 2005. Pulmonary artery catheter was used to investigate hemodynamic profile.

RESULTS

The mechanism of arterial hypotension consisted of decrease of vascular tone (SVRI was 1503 +/- 624 dyn x s x cm(5) x m(2)) and relative hypovolemia (CVP: 4.5 +/- 2.6 torr, PAWP: 7.4 +/- 3.5 torr). In all cases arterial hypotension was corrected with phenylephrine after failure to respond to fluid resuscitation alone. Fluid balance was positive over the next 72 h. Twenty-seven percent of patients had transitory thyroid insufficiency. In these situations dopamine was administrated as symptomatic therapy and dose of thyroid hormone was increased. Mortality was 53%.

CONCLUSION

Hypothalamic damage can result in life-threatening vasodilatory arterial hypotension after sellar region tumor surgery. beta-Sympatomimetics are indicated in cases with thyroid insufficiency.

[Vasopressin for therapy of persistent traumatic hemorrhagic shock: The VITRIS.at study]

While fluid management is established in controlled hemorrhagic shock, its use in uncontrolled hemorrhagic shock is being controversially discussed, because it may worsen bleeding. In the irreversible phase of hemorrhagic shock that was unresponsive to volume replacement, airway management and catecholamines, vasopressin was beneficial due to an increase in arterial blood pressure, shift of blood away from a subdiaphragmatic bleeding site towards the heart and brain and decrease of fluid resuscitation requirements. The purpose of this multicenter, randomized, controlled, international trial is to assess the effects of vasopressin (10 IU IV) vs. saline placebo IV (up to 3 injections at least 5 min apart) in patients with prehospital traumatic hemorrhagic shock that persists despite standard shock treatment. The study will be carried out by helicopter emergency medical service teams in Austria, Germany, Czech Republic, Portugal, the Netherlands and Switzerland. Inclusion criteria are adult trauma patients with presumed traumatic hemorrhagic shock (systolic arterial blood pressure <90 mmHg) that does not respond to the first 10 min of standard shock treatment (endotracheal intubation, fluid resuscitation and use of vasopressors) after arrival of the first emergency physician at the scene. The time window for randomization will close after 30 min of shock treatment. Exclusion criteria are terminal illness, no intravenous access, age <18 years, injury >60 min before randomization, cardiac arrest before randomization, presence of a do-not-resuscitate order, untreated tension pneumothorax, untreated cardiac tamponade, or known pregnancy. Primary study end-point is the hospital admission rate, secondary end-points are hemodynamic variables, fluid resuscitation requirements and hospital discharge rate.

Arginine vasopressin as a supplementary vasopressor in refractory hypertensive, hypervolemic, hemodilutional therapy in subarachnoid hemorrhage

INTRODUCTION

Hypertensive, hypervolemic, and hemodilutional (HHH) therapy for vasospasm in subarachnoid hemorrhage (SAH) refractory to phenylephrine requires high doses of catecholamines, leading to adverse adrenergic effects. Arginine vasopressin (AVP) has been shown to stabilize advanced shock states while facilitating reduction of catecholamine doses, but its use has never been reported in SAH. In this retrospective study, we investigated the hemodynamic effects and feasibility of supplementary AVP in refractory HHH therapy in SAH.

METHODS

Hemodynamic response (mean arterial pressure [MAP], heart rate, central venous pressure, cardiac index, systemic vascular resistance index, and end diastolic volume index) to a supplementary AVP infusion (0.01-0.04 IU/minute) was recorded within the first 24 hours in 22 patients. Secondary endpoints (serum sodium concentration, incidence of vasospasm, and intracranial pressure [ICP]) were compared to controls on HHH therapy with phenylephrine alone.

RESULTS

After initiation of AVP, MAP increased significantly compared to baseline. Phenylephrine doses decreased significantly, whereas other hemodynamic parameters remained stable. Serum sodium concentrations decreased similarly in both groups (-5 +/- 7 mmol/L versus -6 +/- 4 mmol/L; p = 0.25). No detrimental effects on vasospasm incidence or ICP and cerebral perfusion pressure were noted.

CONCLUSION

AVP may be considered as an alternative supplementary vasopressor in refractory HHH therapy with phenylephrine in SAH. Although we did not observe any deleterious effect of AVP on cerebral circulation, close observation for development of cerebral vasospasm should be undertaken, until it is clearly demonstrated that AVP has no adverse effects on regional cerebral blood flow and symptomatic cerebral vasospasm. Our limited data suggest that low-dose AVP does not cause brain edema, but further study is merited.

Systemic complications after head injury: a clinical review

Non-neurological organ dysfunction is common after traumatic brain injury and is an independent contributor to morbidity and mortality. It represents a risk factor that is potentially amenable to treatment, and early recognition and prompt intervention may improve outcome. This article reviews the current evidence for the mechanisms and treatment of non-neurological organ dysfunction after head injury.

Early use of terlipressin in catecholamine-resistant shock improves cerebral perfusion pressure in severe traumatic brain injury

BACKGROUND

Maintaining adequate cerebral perfusion pressure is an essential aspect in the treatment of severe acute brain injury. To accomplish this therapeutic goal vasopressors are usually required. Vasopressin is an important endogenous stress hormone and the infusion of low-dose vasopressin and terlipressin has been used to reverse severe hypotension.

CASE REPORT

A 14-year-old male patient was admitted to the emergency room after a motorcycle accident. The patient had suffered severe traumatic brain injury, the Glasgow coma score (GCS) was four and there were signs of aspiration of gastric contents. Systemic inflammatory response syndrome and shock refractory to fluid management, norepinephrine and steroid replacement ensued. A terlipressin infusion, as a bolus dose of 1 mg, is associated with the ability to improve cerebral perfusion pressure with concomitant reduction of 80% of norepinephrine doses.

DISCUSSION

The present report illustrates the potential benefits of terlipressin in refractory shock in a patient with severe traumatic brain injury. An increase in cerebral perfusion pressure (CPP) and a huge decrease in the dose of norepinephrine were observed. In the setting of severe brain injury associated with refractory hypotension, terlipressin may improve mean arterial pressure and cerebral perfusion pressure.

CONCLUSION

In the setting of severe brain injury associated with refractory hypotension, terlipressin may have a role as a rescue therapy.

Vasopressin during cardiopulmonary resuscitation and different shock states: a review of the literature

Vasopressin administration may be a promising therapy in the management of various shock states. In laboratory models of cardiac arrest, vasopressin improved vital organ blood flow, cerebral oxygen delivery, the rate of return of spontaneous circulation, and neurological recovery compared with epinephrine (adrenaline). In a study of 1219 adult patients with cardiac arrest, the effects of vasopressin were similar to those of epinephrine in the management of ventricular fibrillation and pulseless electrical activity; however, vasopressin was superior to epinephrine in patients with asystole. Furthermore, vasopressin followed by epinephrine resulted in significantly higher rates of survival to hospital admission and hospital discharge. The current cardiopulmonary resuscitation guidelines recommend intravenous vasopressin 40 IU or epinephrine 1mg in adult patients refractory to electrical countershock. Several investigations have demonstrated that vasopressin can successfully stabilize hemodynamic variables in advanced vasodilatory shock. Use of vasopressin in vasodilatory shock should be guided by strict hemodynamic indications, such as hypotension despite norepinephrine (noradrenaline) dosages >0.5 mug/kg/min. Vasopressin must never be used as the sole vasopressor agent. In our institutional routine, a fixed vasopressin dosage of 0.067 IU/min (i.e. 100 IU/50 mL at 2 mL/h) is administered and mean arterial pressure is regulated by adjusting norepinephrine infusion. When norepinephrine dosages decrease to 0.2 microg/kg/min, vasopressin is withdrawn in small steps according to the response in mean arterial pressure. Vasopressin also improved short- and long-term survival in various porcine models of uncontrolled hemorrhagic shock. In the clinical setting, we observed positive effects of vasopressin in some patients with life-threatening hemorrhagic shock, which had no longer responded to adrenergic catecholamines and fluid resuscitation. Clinical employment of vasopressin during hemorrhagic shock is experimental at this point in time.

Arginine vasopressin as a rescue vasopressor agent in the operating room

PURPOSE OF REVIEW

This review gives an overview of the current knowledge and research on the use of arginine vasopressin in cardiac arrest and severe shock states.

RECENT FINDINGS

Animal models have revealed the effectiveness of arginine vasopressin in increasing vital organ perfusion during cardiopulmonary resuscitation. A multicentre trial compared arginine vasopressin and epinephrine in out-of-hospital cardiac arrest, and documented a significant improvement in hospital discharge rates in arginine vasopressin-treated (up to 2 x 40 IU) patients with asystole, and a significant benefit of the combined administration of arginine vasopressin and epinephrine on hospital discharge, irrespective of the underlying electrocardiographic rhythm. The stabilization of advanced shock states unresponsive to conventional therapy can be achieved by supplementary arginine vasopressin (1-4 IU/h). A randomized, controlled trial found that the combined infusion of arginine vasopressin and norepinephrine was superior to norepinephrine alone in reversing advanced vasodilatory shock. Furthermore, the successful employment of arginine vasopressin in uncontrolled haemorrhagic shock and other shock states, such as anaphylaxis, hypotension during spinal/epidural anaesthesia, postcardiotomy shock, acute brain injury, brain-dead organ donors, perioperative hypotension in patients chronically treated with angiotensin-converting enzyme inhibitors, shock after pheochromocytoma surgery, and carcinoid crisis have been reported.

SUMMARY

Whereas arginine vasopressin in combination with epinephrine can significantly increase hospital discharge in cardiac arrest, arginine vasopressin combined with catecholamines improved haemodynamics in vasodilatory and haemorrhagic shock, but effects on outcome remain unknown. Nonetheless, in the perioperative setting, arginine vasopressin may already be considered as a potent adjunct vasopressor agent in advanced shock states unresponsive to conventional therapy.

Effects of arginine vasopressin during resuscitation from hemorrhagic hypotension after traumatic brain injury

OBJECTIVE

Two series of experiments were designed to evaluate whether early arginine vasopressin improves acute outcome following resuscitation from traumatic brain injury and severe hemorrhagic hypotension.

DESIGN

Prospective randomized, blinded animal study.

SETTING

University laboratory.

SUBJECTS

Thirty-three swine.

INTERVENTIONS

In series 1 (n = 19), after traumatic brain injury with hemorrhage and 12 mins of shock (mean arterial pressure approximately 20 mm Hg), survivors (n = 16) were initially resuscitated with 10 mL/kg crystalloid. After 30 mins, crystalloid and blood with either 0.1 unit x kg(-1) x hr(-1) arginine vasopressin or placebo was titrated to a mean arterial pressure target >or=60 mm Hg. After 90 mins, all received mannitol and the target was cerebral perfusion pressure >or=60 mm Hg. To test cerebrovascular function, 7.5% inhaled CO2 was administered periodically. In series 2 (n = 14), the identical protocol was followed except the shock period was 20 mins and survivors (n = 10) received a bolus of either arginine vasopressin (0.2 units/kg) or placebo during the initial fluid resuscitation.

MEASUREMENTS AND MAIN RESULTS

In series 1, by 300 mins after traumatic brain injury with arginine vasopressin (n = 8) vs. placebo (n = 8), the fluid and transfusion requirements were reduced (both p < .01), intracranial pressure was improved (11 +/- 1 vs. 23 +/- 2 mmHg; p < .0001), and the CO2-evoked intracranial pressure elevation was reduced (7 +/- 2 vs. 26 +/- 3 mm Hg, p < .001), suggesting improved compliance. In series 2, with arginine vasopressin vs. placebo, cerebral perfusion pressure was more rapidly corrected (p < .05). With arginine vasopressin, five of five animals survived 300 mins, whereas three of five placebo animals died. The survival time with placebo was 54 +/- 4 mins (p < .05 vs. arginine vasopressin).

CONCLUSIONS

Early supplemental arginine vasopressin rapidly corrected cerebral perfusion pressure, improved cerebrovascular compliance, and prevented circulatory collapse during fluid resuscitation of hemorrhagic shock after traumatic brain injury.

Employing vasopressin as an adjunct vasopressor in uncontrolled traumatic hemorrhagic shock. Three cases and a brief analysis of the literature

Resuscitation of patients in hemorrhagic shock remains one of the most challenging aspects of trauma care. We showed in experimental studies that vasopressin, but not fluid resuscitation, enabled short-term and long-term survival in a porcine model of uncontrolled hemorrhagic shock after penetrating liver trauma. In this case report, we present two cases with temporarily successful cardiopulmonary resuscitation (CPR) using vasopressin and catecholamines in uncontrolled hemorrhagic shock with subsequent cardiac arrest that was refractory to catecholamines and fluid replacement. In a third patient, an infusion of vasopressin was started before cardiac arrest occurred; in this case, we were able to stabilize blood pressure thus allowing further therapy. The patient underwent multiple surgical procedures, developed multi-organ failure, but was finally discharged from the critical care unit without neurological damage.