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

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Abstract

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 end points (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 (−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.

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Authors and Affiliations

  1. Department of Intensive Care Medicine, University Hospital Bern, Switzerland

    Martin W. Dunser

  2. Division of Critical Care Medicine, Departments of Anesthesiology, Surgery, and Medicine, University of Florida College of Medicine, Gainesville, Florida

    Andrea Gabrielli & A. Joseph Layon

  3. Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Austria

    Volker Wenzel

  4. Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Massachusetts General Hospital/Brigham Women’s Hospital, Harvard Medical School, 55 Fruit St., Blake 12, 02114, Boston, MA

    Susanne Muehlschlegel

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  1. Susanne Muehlschlegel
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  2. Martin W. Dunser
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Correspondence to Susanne Muehlschlegel.

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Muehlschlegel, S., Dunser, M.W., Gabrielli, A. et al. Arginine vasopressin as a supplementary vasopressor in refractory hypertensive, hypervolemic, hemodilutional therapy in subarachnoid hemorrhage. Neurocrit Care 6, 3–10 (2007). https://doi.org/10.1385/NCC:6:1:3

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