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Eur J Cardiothorac Surg 2006;30:689
© 2006 Elsevier Science NL

Letters to the Editor

Is vasopressin really superior to norepinephrine in reversing milrinone-induced vasodilation?

Matthias Lange*, Hugo Van Aken, Martin Westphal

Department of Anaesthesiology and Intensive Care, University of Muenster, Albert-Schweitzer-Str. 33, 48149 Muenster, Germany

Received 16 May 2006; accepted 19 July 2006.

* Corresponding author. Tel.: +49 251 8347255; fax: +49 251 8348667. (Email: lange-m{at}anit.uni-muenster.de).

Key Words: Vasopressin • Norepinephrine • Off-pump coronary bypass • Milrinone

Jeon et al. [1] report that both norepinephrine and vasopressin restored the milrinone-induced decrease in systemic vascular resistance in patients undergoing off-pump coronary artery bypass surgery. Interestingly, only ‘low-dose’ vasopressin decreased the pulmonary vascular resistance/systemic vascular resistance ratio. The conclusion that vasopressin is superior to norepinephrine in restoring arterial blood pressure in patients with pulmonary hypertension and right heart failure [1] may not be entirely correct and should be reconsidered due to three important aspects:

Firstly, the vasopressin doses used in the presented study (up to 0.16 U/min) [1] markedly exceeded the doses (0.01–0.04 U/min) currently recommended for the treatment of patients with septic shock related to relative vasopressin deficiency [2,3].

In addition, the increase in mean arterial pressure (MAP) in the norepinephrine group was stronger than in the vasopressin group (+29% vs +20%). This difference in goal-MAP indicates that the doses of norepinephrine and vasopressin were not equivalent [1].

Finally, previous experimental [4] and clinical trials [5] demonstrated that conventional vasopressors, such as norepinephrine, should not be replaced by vasopressin [3]. In this context it is noteworthy that ‘pharmacological’ vasopressin doses needed to restore MAP to the same extent as norepinephrine were associated with increased gastric-arterial Formula gradients [4,5], most likely due to impaired splanchnic mucosal microcirculation.

In summary, it remains unclear if vasopressin is superior to norepinephrine in reversing milrinone-induced hypotension, especially because outcome variables were not determined in the study by Jeon et al. [1].

Footnotes

{star} The authors of the original paper [1] were invited to reply to this Letter to the Editor but they did not respond.

References

  1. Jeon Y, Ryu JH, Lim YJ, Kim CS, Bahk JH, Yoon SZ, Choi JY. Comparitive hemodynamic effects of vasopressin and norepinephrine after milrinone-induced hypotension in off-pump coronary artery bypass surgical patients. Eur J Cardiothorac Surg. 2006;29:952-956.[Abstract/Free Full Text]
  2. Holmes CL, Walley KR, Chittock DR, Lehman T, Russell JA. The effects of vasopressin on hemodynamics and renal function in severe septic shock: a case series. Intensive Care Med 2001;27:1416-1421.[CrossRef][Medline]
  3. Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmermann JL, Vincent JL, Levy MM. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32:858-873.[CrossRef][Medline]
  4. Martikainen TJ, Tenhunen JJ, Uusaro A, Ruokonen E. The effects of vasopressin on systemic and splanchnic hemodynamics and metabolism in endotoxin shock. Anesth Analg 2003;97:1756-1763.[Abstract/Free Full Text]
  5. Klinzing S, Simon M, Reinhart K, Bredle DL, Meier-Hellman A. High-dose vasopressin is not superior to norepinephrine in septic shock. Crit Care Med 2003;31:2646-2650.[CrossRef][Medline]




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