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Vasopressin Receptor Agonist (V1/V2) Pregnancy: Use with caution — V1 activation causes uterine contractions; avoid in first/second trimester; use only for life-threatening vasoplegic shock with obstetric specialist input

Vasopressin (Surgical — Vasopressor/Haemostasis)

Brand names: Argipressin, Pitressin

Adult dose

Dose: Vasodilatory shock (post-cardiac surgery/septic): 0.03–0.04 units/min IV fixed dose (adjunct to noradrenaline); Variceal bleeding (dilute protocol): 0.2–0.4 units/min IV; Intraoperative haemostasis (local injection): 0.2–1 unit diluted in saline, injected submucosal/perihepatic
Route: IV infusion; or local injection (surgical site)
Frequency: Continuous infusion (vasopressor); single local doses (haemostasis)
Max: 0.04 units/min (vasopressor); titrated for variceal protocol
V1 receptor activation: splanchnic and peripheral vasoconstriction. V2 receptor: renal water reabsorption. Fixed low-dose vasopressin (0.03 units/min) as adjunct reduces noradrenaline requirements in vasoplegic shock by 30–40%. Local injection used by surgeons for haemostasis in laparoscopic surgery, myomectomy, ENT procedures.

Paediatric dose

Dose: 0.0003–0.002 units/min/kg
Route: IV infusion
Frequency: Continuous
Max: 0.002 units/kg/min
Paediatric vasoplegic shock: 0.0003–0.002 units/kg/min under specialist guidance. Cardiac surgery paediatric vasoplegic syndrome: fixed low-dose adjunct.

Dose adjustments

Renal

No dose adjustment — V2 renal effect is therapeutic (anti-diuretic). Monitor sodium (hyponatraemia from excess V2 activation).

Hepatic

Use with caution in liver disease — hepatic clearance; also used specifically for variceal bleeding in cirrhosis.

Paediatric weight-based calculator

Paediatric vasoplegic shock: 0.0003–0.002 units/kg/min under specialist guidance. Cardiac surgery paediatric vasoplegic syndrome: fixed low-dose adjunct.

Clinical pearls

  • VASST trial (NEJM 2008): vasopressin 0.03 units/min vs noradrenaline alone in septic shock — no overall mortality benefit; pre-specified subgroup: mortality benefit in less severe septic shock (noradrenaline <15 mcg/min). Current guideline (SSC 2021): vasopressin added to noradrenaline to achieve MAP target, reduce noradrenaline dose, and as second-line vasopressor
  • Post-cardiac surgery vasoplegic syndrome: vasopressin deficiency occurs after CPB — vasopressin levels fall dramatically post-bypass; replacement with 0.03 units/min restores vascular tone without increasing HR (unlike catecholamines); preferred second vasopressor in cardiac surgery ICU
  • Local haemostasis — surgical technique: dilute vasopressin 0.5 units/mL infiltrated submucosally reduces intraoperative blood loss in myomectomy, TURBT, laparoscopic hysterectomy, and ENT procedures (adenotonsillectomy) — cardiac monitoring mandatory

Contraindications

  • Chronic nephritis with nitrogen retention
  • Ischaemic heart disease (coronary vasoconstriction risk at high doses)
  • Peripheral vascular disease (V1-mediated ischaemia)

Side effects

  • Peripheral vasoconstriction and ischaemia
  • Coronary artery spasm/myocardial ischaemia (high doses)
  • Hyponatraemia (V2 activation — water retention)
  • Abdominal cramps (splanchnic vasoconstriction)
  • Decreased cardiac output (afterload increase)

Interactions

  • Noradrenaline (synergistic — used together in vasoplegic shock; additive ischaemia at high doses)
  • NSAIDs (reduce diuretic V2 effect)
  • Lithium (antagonises V2 — reduces antidiuretic effect)

Monitoring

  • Continuous arterial line BP monitoring
  • ECG (ST changes — coronary vasoconstriction)
  • Serum sodium (hyponatraemia from V2 effect)
  • Cardiac output monitoring
  • Peripheral perfusion (digital ischaemia)

Reference: BNFc; BNF 90; VASST Trial (NEJM 2008); Surviving Sepsis Campaign 2021; ESC Heart Failure Guidelines; MHRA SPC Argipressin. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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