Vasopressin vs. Levophed

[sugarmagnoliaRN]

This is kind of a newbie CCU nurse question but I'd really appreciate y'alls help understanding this! I just started in a cardiac ICU and there is a strong preference for vasopressin over levophed... I understand why Levo is good for sepsis because it jacks up your SVR and causes vasoconstriction, which are generally not things you want for cardiac patients (especially not with cariogenic shock). But doesn't vasopressin have a lot of the same effects? I will say I see it more on the post-op patients (e.g. CABG) than the pts that come in with cardiogenic shock. I'm trying to research this on my own but I'm not really finding a clear answer as to why it would be preferred over Levo. Can anyone with more experience than me shed some light on this? Thank you in advance!! :)

[Annaiya, NP]

I don't work with adults or cardiac patients so someone correct me if there's another reason but my guess would be that vasopressin has less effect on cardiac O2 demand than norepinephrine.

[ArmaniX, MSN, APRN]

I don't work CCU (we primarily use levophed as first choice) .. my thoughts were that neo would be the first option for cardiac patients but not an expert. Hopefully someone can inform us.

[sugarmagnoliaRN]

Thanks for the input y'all! Annaiya, that does make sense about Levo increasing myocardial O2 demand. Armanix- I have actually never seen Neo used in our unit - I think the first-line choices there are epi and dopamine. But then again, I'm no expert yet either

[arnwest]

My understanding is that it depends on what kind of shock the patient is in. According to Surviving Sepsis, levo is the first line pressor, followed by vaso, to decrease levo requirements. Sometimes I see Neo used if the patient doesn't have a central line. But I would think inotropes would be preferred in cardiogenic shock.

[sugarmagnoliaRN]

My understanding is that it depends on what kind of shock the patient is in. According to Surviving Sepsis, levo is the first line pressor, followed by vaso, to decrease levo requirements. Sometimes I see Neo used if the patient doesn't have a central line. But I would think inotropes would be preferred in cardiogenic shock.

That's my understanding too; my question is why vasopressin would be a drug used frequently in cardiac surgery patients, where you don't necessarily want an increased SVR and thus increased cardiac workload. The answer I've found so far seems to be that endogenous stores of vasopressin are depleted after cardiac surgery.

[calivianya, BSN, RN]

That's my understanding too; my question is why vasopressin would be a drug used frequently in cardiac surgery patients, where you don't necessarily want an increased SVR and thus increased cardiac workload. The answer I've found so far seems to be that endogenous stores of vasopressin are depleted after cardiac surgery.

Yep on the last part! I watched an endocrine presentation as part of the orientation process for a new PRN job, and it talked about vasopressin requirements being easily 100-200x normal when a body is under extreme stress, such as shock.

"Studies have shown that in acute shock states, serum vasopressin levels increase rapidly and then decrease in prolonged shock states leading to a relative deficiency of vasopressin."

What are the current recommendations regarding the use of vasopressin in the treatment of shock?

That link is great; it sums up a ton of research articles on vasopressin use - mostly in septic shock, but you can definitely extrapolate some of the principles to cardiogenic shock.

[PaSSiNGaS, MSN]

The reason you see vasopressin used more with cardiac surgery is due to the bypass pump. Having the blood come into contact causes a large vasoplegic response and usually can be unresponsive to other pressors. Google the actual mechanism of action of Vasopressin vs Norepinephrine and you will see why.

[sugarmagnoliaRN]

Thanks y'all!! I appreciate your expertise!

[sugarmagnoliaRN]

In case anyone else has come across this thread and would like more info re: vasoplegic responses after cardiac surgery, this is a good article: Vasoplegic Syndrome after Off-Pump Coronary Artery Bypass Surgery

[nmsumurse]

there are also no receptors for vasopressin in the pulmonary vasculature, there are for levo, epi. When you have cardiac pt that are fluid optimized increasing pressors will effect your pa pressures.

[sugarmagnoliaRN]

there are also no receptors for vasopressin in the pulmonary vasculature, there are for levo, epi. When you have cardiac pt that are fluid optimized increasing pressors will effect your pa pressures.

Thank you!!