Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Jun 2008
ReviewArginine vasopressin as a rescue vasopressor to treat epidural anaesthesia-induced arterial hypotension.
Epidural anaesthesia is a well-established and recognized technique in anaesthetic practice. Its benefits are multiple and range from positive effects on the respiratory and cardiocirculatory system, a reduced need for analgesics and decreased costs to earlier hospital discharge. Disadvantages like sympathetic blockade followed by hypotension, bradycardia, and cardiac arrest, however, must be taken into consideration. ⋯ In case reports and a small clinical study, administration of AVP or one of its analogues could rapidly reverse hypotension and restore cardiovascular stability. Because no major controlled clinical trial has yet evaluated the effects of AVP on morbidity, AVP can so far not be recommended as a first-line drug to treat cardiovascular instability during epidural anaesthesia. In refractory cases, however, the use of AVP as a rescue vasopressor may be beneficial.
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Best Pract Res Clin Anaesthesiol · Jun 2008
ReviewRole of vasopressinergic V1 receptor agonists in the treatment of perioperative catecholamine-refractory arterial hypotension.
Three pathways are critically involved in blood pressure regulation during anaesthesia, i.e. the sympathetic nervous system, the renin angiotensin system (RAS), and the vasopressinergic system. The fact that anaesthetic agents typically blunt the regulatory role of the adrenergic system emphasises the importance of the remaining compensatory mechanisms. In patients chronically treated with RAS antagonists, such as angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists, however, this mechanism is also blunted, possibly resulting in absolute dependency of blood pressure regulation on the vasopressinergic system. ⋯ In the absence of catecholamine resistance and RAS blockade, administration of V1 agonists may contribute to a dose-dependent reduction in regional splanchnic vasoconstriction. Likewise, bolus infusion may result in coronary vasospasm and is thus not recommended for routine clinical use. Future large-scale randomized, controlled clinical trials are warranted to evaluate the role of V1 agonists in the treatment of perioperative hypotension in more detail.
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Best Pract Res Clin Anaesthesiol · Jun 2008
Review"Terlipressin in the treatment of septic shock: the earlier the better"?
Terlipressin, a long-acting vasopressinergic V1 agonist, is increasingly used to increase mean arterial blood pressure in the common setting of catecholamine-refractory septic shock. Traditionally, terlipressin has been used as drug of last resort and administered as intermittent high-dose bolus infusion (1-2 mg every 4 to 6 hours). ⋯ Small-scale clinical studies suggest that low-dose terlipressin, when given as a first-line vasopressor agent, is safe. Randomised, clinical multicenter trials are now needed to investigate whether or not early institution of low-dose continuous terlipressin infusion improves overall outcome of patients suffering from vasodilatory shock states.
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Best Pract Res Clin Anaesthesiol · Jun 2008
ReviewVasopressin analogues in the treatment of shock states: potential pitfalls.
Vasopressin analogues are increasingly used for haemodynamic support of catecholamine-refractory, hyperdynamic septic shock. Arginine vasopressin (AVP) and terlipressin (TP) effectively increase mean arterial pressure and reduce catecholamine requirements in this condition. However, the use of either of the drugs may be linked to relevant haemodynamic side effects, including reductions in cardiac output, oxygen delivery and mixed-venous oxygen saturation. ⋯ Maximum doses of 0.03 (-0.067) U min(-1) of AVP or 2 microg kg(-1) h(-1) of TP, respectively, should not be exceeded. Aggressive fluid therapy may prevent adverse haemodynamic effects linked to infusion of either AVP or TP. Finally, platelet count, surrogate variables of hepatic dysfunction, electrolytes and osmolality should be strictly monitored in patients treated with vasopressin analogues.
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Best Pract Res Clin Anaesthesiol · Jun 2008
ReviewArginine vasopressin vs. terlipressin in the treatment of shock states.
The synthetic vasopressin analogue, terlipressin, is being increasingly used to treat catecholamine-resistant hypotension in septic shock and other conditions. While terlipressin holds some theoretical and anecdotal advantages over vasopressin, this has not been formally tested in prospective randomised trials. This review analyses the published literature and makes comparisons, where possible, between vasopressin and terlipressin.