Vasopressin as adjunct vasopressor for vasodilatory shock due to non-occlusive mesenteric ischemia

Abstract

We present the case of an 83-year-old patient who underwent cardiac surgery and developed postoperative non-occlusive mesenteric ischemia (NOMI), which was treated with a local intra-arterial papaverine and prostaglandin E1 infusion. After successful mesenteric reperfusion, a multiple organ dysfunction syndrome with severe cardiovascular failure developed. High norepinephrine dosages (1.09 microg/kg body weight/min) and catecholamine-related complications (tachycardiac atrial fibrillation) required initiation of supplementary argininevasopressin (AVP) infusion (4 U/h). AVP stabilized vasodilatory shock, ensured adequate gut perfusion pressure and had no adverse clinical or angiographic effects on restitution of gut integrity. In conclusion, after reperfusion of NOMI in this patient, adjunct AVP therapy combined with local vasodilator infusion was beneficial as a potentially life-saving vasopressor.

Poisoning-related bowel infarction: Characteristics and outcomes

“…Similarly, vasopressin and terlipressin have been implicated in intestinal ischemia although vasopressin was successfully used in one case to treat vasodilatory shock due to nonocclusive mesenteric ischemia. 38 Effects of catecholamines may depend upon the doses given, the combination of agents, as well as the mechanisms of shock. Indirect monitoring of splanchnic perfusion using gastric tonometry or of splanchnic blood flow using indocyanine green infusion or laser Doppler has been recommended for patients in shock and being treated with vasopressors.…”

A novel approach for percutaneous treatment of massive nonocclusive mesenteric ischemia: Tolazoline and glycerol trinitrate as effective local vasodilators

“…In contrast to OMI which requires primary surgical therapy, patients with NOMI need vasodilator medication [6]. For minimization of systemic effects as hypotension, drug application has to be performed locally via a transarterial catheter [1]. Apart from tolazoline, phenoxybenzamine, dihydrogen adenosine triphosphate, and captopril, especially, papaverine has been used sucessfully [6].…”

“…In contrast to occlusive mesenteric ischemia (OMI), which is generated by obstruction of the arterial flow (thrombosis or embolism), macro-and microvascular vasoconstriction is the major pathophysiological process [1]. Several diseases, especially with low cardiac output (myocardial infarction or cardiac surgery), have been associated with NOMI [2].…”

Comparison of first-line and second-line terlipressin versus sole norepinephrine in fulminant ovine septic shock

“…Additionally, the reluctant use of AVP in clinical settings might be based on low experience and the fear of clinicians regarding intestinal or digital ischemia as well as reduced global oxygen delivery and cardiac output 4 , 5 . In contrast, evidence suggests that rather sepsis itself is the reason for such complications, and the use of vasopressin analogues does not trigger ischemic events 6 , 7 . Notably, administration of AVP in septic patients has been proven safe as supplemental (The Vasopressin in Septic Shock (VASST)-Trial) as well as first-line therapy (Vasopressin vs Norepinephrine on Kidney Failure in Patients With Septic Shock (VANISH)- Trial) 8 , 9 .…”