Vasopressin presser effects in critically ill children during evaluation for brain death and organ recovery

Background: Vasopressin (VP) shows promise as a presser agent in animals and adult human cardiac arrest and resuscitation, but has not been studied for presser effect in critically ill or arrested children. VP infusion is routine treatment for diabetes insipidus during brain death evaluation and organ recovery. We hypothesized that low dose VP infusion during organ recovery in critically ill children exerts a presser effect, without major organ toxicity. Methods: 34 VP-treated and 29 age-matched critically ill controls(C) less than or equal to 18 years were retrospectively reviewed during brain death evaluation and organ recovery. VP infusion protocol titrated VP dose clinically to urine output, with high variability. Presser and inotrope management was titrated clinically to BP, cerebral perfusion and central venous pressures (when available) and peripheral perfusion with similar protocol targets for pre-load in VP and C groups. Outcome measures include dose, type and number of pressors and inotropes. Organ function was assessed at recovery and 48 h post-transplant by independent surgeon and transplant program organ function criteria. Analysis by Odds Ratio (OR), and chi-square. Results: VP dose averaged 0.041 +/- 0.069 U/kg/h. Average baseline mean arterial pressure (MAP) before VP infusion was 79 +/- 17 mmHg VP and 76 +/- 14 mmHg C (P = 0.6). Subsequent average MAP were: 82 +/- 21 mmHgVP after VP infusion versus 71 +/- 16 mmHg C (P = 0.01) and 80 +/- 14 mmHg VP versus 68 +/- 22 mmHg C (P = 0.01). Ability to wean/stop pressors and inotropes was: dopamine (14/23) 42% VP versus (10/26) 38% C (P = 0.75), dobutamine (4/7) 57% VP versus (0/6) 0% C (P = 0.026), epinephrine (4/5) 80% VP versus (0/6) 0% C (P = 0.006), norepinephrine/phenylephrine (4/4) 100% VP versus (2/5) 40% C (P = 0.057). Alpha agonist presser dependence was successfully weaned from 7/9 (78%) VP versus 0/9 (0%) C: odds ratio = 7.3, (P < 0.01). There was no VP induced dysrhythmia, hypertension, anuria or toxicity reported. Good organ recovery function was not significantly different at recovery or 48 h post-transplant for kidney (79% VP versus 69% C, P = 0.068), liver (87% VP versus 95% C, P = 0.533), or heart (90% VP versus 71% C, P = 0.11). Conclusions; Low dose vasopressin infusion exerts a presser effect in critically ill children treated for diabetes insipidus during brain death and organ recovery. VP treated patients were 7.3 times more likely to wean from alpha agonists than comparably managed age matched controls, without adverse affect on transplant organ function. We speculate that further prospective assessment of VP safety and efficacy as a presser adjunct for resuscitation of critically ill children is warranted. (C) 2000 Elsevier Science Ireland Ltd. All rights reserved.