Norepinephrine Tapering and Vasopressin Addition Protocol

Introduction to Vasopressin and Norepinephrine Use

The Society of Critical Care Medicine recommends adding vasopressin to norepinephrine when the target mean arterial pressure (MAP) cannot be achieved with initial vasopressor therapy, in patients who require vasopressor support to maintain a MAP of 65 mmHg despite adequate fluid resuscitation 1

Initiate vasopressin when norepinephrine requirements remain elevated or when you need to decrease norepinephrine dosage to achieve target MAP, with a standard dose of 0.03 units/minute (range 0.01-0.03 units/minute), in patients who are critically ill and require vasopressor support 1, 2

The standard dose of vasopressin is 0.03 units/minute, with a range of 0.01-0.03 units/minute, and should not be used as monotherapy, but rather added to norepinephrine, in patients who require vasopressor support to maintain a MAP of 65 mmHg despite adequate fluid resuscitation 1, 2
Alternative dosing from trauma literature: a bolus of 4 IU followed by 0.04 IU/min has shown benefit in hemorrhagic shock, in patients with severe trauma and hemorrhagic shock 3

Ensure central venous access for safe administration and place arterial catheter for continuous blood pressure monitoring as soon as practical, in patients who require vasopressor support to maintain a MAP of 65 mmHg despite adequate fluid resuscitation 1, 4
Target MAP ≥65 mmHg in most patients, with a gradual tapering strategy after vasopressin addition, in patients who are critically ill and require vasopressor support 1, 2, 4

Once vasopressin is added at 0.03 units/minute, you can either raise MAP to target or decrease norepinephrine dosage while maintaining hemodynamic stability, with a preference for gradual dose reduction over abrupt discontinuation, in patients who require vasopressor support to maintain a MAP of 65 mmHg despite adequate fluid resuscitation 1

Monitor blood pressure and heart rate every 5-15 minutes during initial titration, and assess perfusion markers beyond just MAP, including capillary refill, urine output, lactate clearance, and mental status, in patients who are critically ill and require vasopressor support 4
Watch for signs of excessive vasoconstriction, such as cold extremities, decreased urine output, and rising lactate, in patients who require vasopressor support to maintain a MAP of 65 mmHg despite adequate fluid resuscitation 1

If hemodynamic targets remain unmet despite norepinephrine plus vasopressin, add epinephrine as a third agent rather than increasing vasopressin beyond 0.03-0.04 units/minute, in patients who are critically ill and require vasopressor support 1
Consider dobutamine (up to 20 mcg/kg/min) for persistent hypoperfusion despite adequate vasopressor support, particularly with evidence of myocardial dysfunction, in patients who require vasopressor support to maintain a MAP of 65 mmHg despite adequate fluid resuscitation 1, 2, 3

Never use dopamine for renal protection, as it is strongly discouraged and has no benefit, in patients who require vasopressor support to maintain a MAP of 65 mmHg despite adequate fluid resuscitation 1, 2
Avoid dopamine as first-line therapy, as it is associated with higher mortality and more arrhythmias compared to norepinephrine, and should only be used in highly selected patients with low risk of tachyarrhythmias or absolute/relative bradycardia, in patients who are critically ill and require vasopressor support 1, 2
Do not use phenylephrine except in specific circumstances, such as norepinephrine-induced serious arrhythmias, high cardiac output with persistent hypotension, or salvage therapy, in patients who require vasopressor support to maintain a MAP of 65 mmHg despite adequate fluid resuscitation 1, 2
Do not delay norepinephrine initiation waiting to complete entire fluid resuscitation if life-threatening hypotension (systolic BP <80 mmHg) is present, in patients with severe trauma and hemorrhagic shock 2, 3

The American College of Critical Care Medicine recommends weaning norepinephrine first while maintaining vasopressin at 0.03 units/min until hemodynamic stability is achieved, as evidenced by the VASST and VANISH trials 5
The Society of Critical Care Medicine suggests that vasopressin should be withdrawn after weaning norepinephrine, not before, to avoid hemodynamic instability 5

Vasopressin at 0.03 units/min provides catecholamine-independent vasoconstriction through V1a receptors, complementing norepinephrine's adrenergic effects rather than duplicating them 6
The addition of vasopressin aims to reduce norepinephrine requirements and possibly reduce renal replacement therapy needs, according to the European Society of Intensive Care Medicine 5, 7

The Surviving Sepsis Campaign recommends ensuring MAP ≥65 mmHg is sustained for at least 2-4 hours before weaning vasopressors, and verifying adequate tissue perfusion: lactate clearance, urine output ≥0.5 mL/kg/hr, improving mental status, warm extremities with brisk capillary refill 7
The American College of Critical Care Medicine suggests reducing norepinephrine by 0.01-0.02 mcg/kg/min (or 1-2 mcg/min) every 15-30 minutes while maintaining vasopressin at 0.03 units/min, and monitoring MAP continuously via arterial line 5

The European Society of Intensive Care Medicine advises never escalating vasopressin beyond 0.03-0.04 units/min, as higher doses cause cardiac, digital, and splanchnic ischemia without additional hemodynamic benefit 8
The Society of Critical Care Medicine recommends avoiding premature vasopressin withdrawal, as removing vasopressin while maintaining high norepinephrine defeats the purpose of combination therapy and increases hemodynamic instability 5

The American College of Critical Care Medicine suggests that continuous arterial blood pressure monitoring is mandatory, and assessing perfusion beyond MAP: capillary refill, skin temperature, urine output, lactate trends, mental status 8, 7