Vasopressin (ADH) and Furosemide or Bumex drip

[Death and Taxes]

Septic shock on levo and vaso, CKD 3, HFrEF with 4+ pitting edma. My suggestion for albumin was shot down. Attending wants diuretic drip, asked why ADH and a diuretic drip at the same time, told to "read about it" but doesnt make much sense to me. Thoughts? Why not any other pressor besides vasopressin as 2nd line?

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[jdh71]

Septic shock on levo and vaso, CKD 3, HFrEF with 4+ pitting edma. My suggestion for albumin was shot down. Attending wants diuretic drip, asked why ADH and a diuretic drip at the same time, told to "read about it" but doesnt make much sense to me. Thoughts? Why not any other pressor besides vasopressin as 2nd line?

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I don't know that there is amazeball evidence for much in the ICU including choice of second pressor. But certain clinical contexts not withstanding it's a very reasonable second line choice because it's hitting a different receptor. Most of your other pressors have most of their effect flogging alpha1. Why add another alpha1 agonist when you can turn up the norepinephrine or hit an additional receptor.

I don't know enough about the case but most of us try to avoid diuretics while on pressors but sometimes it makes sense.

I'm a big fan of albumin. Use it a lot when I think it makes sense. Critical care in the chronically ill with multiple systems suboptimal at baseline is playing chess looking for positional advantage. A game often of inches not big leaps and bounds.

 

[psychbender]

Your patient has some element of right heart dysfunction. Vasopressin will increase systemic pressure without affecting pulmonary vascular resistance. Diuresis may allow optimization of right heart preload and improve forward flow.

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[Death and Taxes]

Your patient has some element of right heart dysfunction. Vasopressin will increase systemic pressure without affecting pulmonary vascular resistance. Diuresis may allow optimization of right heart preload and improve forward flow.

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How much diuresis will occur with antidiuretic hormone (vasopressin) and a loop diuretic simultaneously, both as infusion? It seems very counterintuitive. Switch off vaso for something else if the goal is decreasing the anasarca through diuresis?

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[jdh71]

How much diuresis will occur with antidiuretic hormone (vasopressin) and a loop diuretic simultaneously, both as infusion? It seems very counterintuitive. Switch off vaso for something else if the goal is decreasing the anasarca through diuresis?

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Lots (assuming kidneys work and cardiac output is good enough). The vasopressin won't be able to fight against a loop diuretic infusion.

 

[SurfingDoctor]

CRRT...

 

[lymphocyte]

Septic shock on levo and vaso, CKD 3, HFrEF with 4+ pitting edma. My suggestion for albumin was shot down. Attending wants diuretic drip, asked why ADH and a diuretic drip at the same time, told to "read about it" but doesnt make much sense to me. Thoughts? Why not any other pressor besides vasopressin as 2nd line?

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Vasopressin has a relatively long half-life and provides a good baseline pressor while you diddle with levo.

Albumin is great. I think ALBIOS and SAFE were generally positive trials and there are lots of signals in the literature that albumin is beneficial in shocked patients. It also helps break diuretic resistance.

But what you're asking is a question of basic physiology: the role of sodium vs free water in edema. Sodium by far plays the dominant role and hence natriuresis with something like frusemide is the goal. Free water makes very, very little difference. That's why you don't see edema in SIADH or when you give DDAVP. Plus, vasopressin retains free water by increased apical expression of aquaporin channels. In shocked patients with maximum neurohumoral activation, all of these channels are already expressed.

 

[Psai]

You're making the assumption that the ahd and diuretic cancel each other out and therefore there's no point in doing both. That makes no sense. Vasopressin is helping with vascular permeability and blood pressure in septic shock, helping keep the intravascular space filled. Diuretics are to get rid of the fluid overload. Sometimes you need to give fluid to get the patient over the hump but as Marik and others have shown, increased fluid administration is associated with increased mortality.

I would do an albumin/diuretic challenge. Sometimes that actually helps to get patients off pressor as they mobilize fluid with improved organ function since they aren't all bogged down in excess fluid. (fluid filled kidneys are crappy just like fluid filled lungs with pulmonary edema and pleural effusion are crappy)

 

[Hamhock]

I think the OP might be confusing ddavp with vasopressin infusion.
Different amino acid synthesis and very different actions.
Not all "vasopressins" are the same.
HH

 

[Death and Taxes]

You're making the assumption that the ahd and diuretic cancel each other out and therefore there's no point in doing both. That makes no sense. Vasopressin is helping with vascular permeability and blood pressure in septic shock, helping keep the intravascular space filled. Diuretics are to get rid of the fluid overload. Sometimes you need to give fluid to get the patient over the hump but as Marik and others have shown, increased fluid administration is associated with increased mortality.

I would do an albumin/diuretic challenge. Sometimes that actually helps to get patients off pressor as they mobilize fluid with improved organ function since they aren't all bogged down in excess fluid. (fluid filled kidneys are crappy just like fluid filled lungs with pulmonary edema and pleural effusion are crappy)

I dont doubt the vascular effects of ADH on V1. I'm saying that a loop diuretic is promoting diuresis proximal within the nephron to ADH working on V2 in the collecting ducts with aquaporin, severely diminishing diuresis.

"In the presence of ADH, the cells are much more permeable to water. At maximal ADH levels, less then 1% of the filtered water is excreted (urine volume 500mls/day)" - some ****ty website and I'm looking for a better primary lit source.

In this particular scenario, not others, I'm arguing that vasopressin isnt an optimal second line pressor if you're attempting diuresis as well

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[Death and Taxes]

I think the OP might be confusing ddavp with vasopressin infusion.
Different amino acid synthesis and very different actions.
Not all "vasopressins" are the same.
HH

Vasopressin = ADH, no? Ddvap wasn't ordered

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[lymphocyte]

I dont doubt the vascular effects of ADH on V1. I'm saying that a loop diuretic is promoting diuresis proximal within the nephron to ADH working on V2 in the collecting ducts with aquaporin, severely diminishing diuresis.

"In the presence of ADH, the cells are much more permeable to water. At maximal ADH levels, less then 1% of the filtered water is excreted (urine volume 500mls/day)" - some ****ty website and I'm looking for a better primary lit source.

In this particular scenario, not others, I'm arguing that vasopressin isnt an optimal second line pressor if you're attempting diuresis as well

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You think vasopressin and frusemide work against each other, which is perhaps true, but I very strongly doubt it's clinically significant with respect to treating edema. For example, you don't need much frusemide to antagonise ADH, even maximal ADH. That's why you can give 20 to 40 mg PO frusemide in SIADH and get excellent free water clearance.

You're also comparing naturesis to pure diuresis. But naturesis is king in resolving edematous states. That's a basic principle of renal physiology. Just think about how free water is distributed across cellular compartments. (UpToDate has an excellent article about this topic written by the man himself Burton Rose).

Finally, VASST showed a pretty striking mortality benefit for low-dose vasopressin instead of extra noradrenaline in less severe septic shock (25.8% relative reduction in 28-day mortality). That's a very fair reason to give vasopressin, regardless of how it might effect diuresis.

 

[jdh71]

I don't understand what all this nerd **** is about.

 

[anbuitachi]

Septic shock on levo and vaso, CKD 3, HFrEF with 4+ pitting edma. My suggestion for albumin was shot down. Attending wants diuretic drip, asked why ADH and a diuretic drip at the same time, told to "read about it" but doesnt make much sense to me. Thoughts? Why not any other pressor besides vasopressin as 2nd line?

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well albumin may temporarily increase blood pressure (or not) but its just temporary. the patient is very edematous so the goal is to get off fluids. like what someone else said, it's more effective to target a difference receptor. what other pressor did you want other than vasopressin? Angio2?

 

[Radetzky]

Vasopressin can only work if there is a medullary concentration gradient. Abolish this with loop diuretics and your vasopressin becomes ineffective at water retention.