B-29: Intraarterial Vasopressin Infusion Therapy
  • Indications
    • Acute GI bleeding not amenable to embolotherapy
  • Contraindications
    • Contrast allergy (premedicate)
    • Clinically significant coronary artery disease
    • Recent myocardial infarction
    • Advanced cerebral vascular disease
    • Advanced peripheral vascular disease
    • Congestive heart failure
    • Renal failure with fluid retention
    • Caution in advanced liver disease with portal hypertension
  • Patient Evaluation
    • Able to lie still, cooperate during procedures, tolerate prolonged treatment (2-3 days)
    • Caution in patients with renal, cardiac and liver disease
  • Preprocedure Orders
  • Tools
    • 6 Fr. vascular sheath, 5 Fr. selective catheter (Cobra, RC, Simmons)
    • Coaxial microcatheter (Tracker, Cragg, Sos, etc.) w/ Tohey-Borst adapter
  • Entry site
    • Femoral artery
  • Technique
    • After diagnostic arteriogram insert microcatheter through diagnostic catheter using Tohey-Borst adapter. Position catheter as selectively as possible into offending artery and begin vasopressin infusion.
    • Adjust the infusion rate as follows: The initial infusion rate is 0.2 U/min. A repeat arteriogram is done after 20 minutes of infusion. If there is continued bleeding, the infusion rate is increased to 0.4 U/min and arteriography is performed after an additional 20 minutes. If bleeding persists, embolization or surgery will be necessary. Infusion rates greater than 0.4 U/min are unlikely to be effective and are associated with significant complications. If the vasopressin does control bleeding, secure catheter and sheath at groin with suture, Steristrips, and Tegaderm. Transport the patient to ICU.
    • The initial effective infusion rate is maintained for 24 hours. If there is no clinical evidence of bleeding during that time, the vasopressin dose is tapered by one-half every 12 to 24 hours. After 12 to 24 hours at 0.1 U/min, the vasopressin is stopped and saline or D5W is infused through the microcatheter. If no bleeding occurs within the ensuing 6 to 12 hours, the catheter is removed.
  • Post-procedure Note
    • Note bleeding site and infusion catheter position, and note pulses distal to entry site
  • Post-procedure Infusion Orders
    1. Admit ICU
    2. Strict bed rest with ___ leg kept straight at groin. Restrain leg if necessary.
    3. May elevate HOB 30 degrees maximum. May log roll 30 degrees
    4. Egg crate mattress
    5. Diet: NPO
    6. Strict I/O
    7. Check and record BP, HR, RR, ___pedal pulses and ___ groin for bleeding/hematoma
      • q 15 min x 2, then
      • q 30 min x 4, then
      • q 1 hour if stable
    8. Check all stool, NGT aspirate and emesis forblood/occult blood
    9. Electrolytes (chem 7) q 8 hours minimum
    10. Call H/O for DBP <60, abdominal pain, chest pain, loss of pedal pulses or evidence of active GI bleeding
    11. If bleeding or hematoma occurs, apply pressure to site, call H/O and notify Special Procedures or radiologist on call
    12. IVF per H/O
    13. Infuse arterial sheath with D5W (or ?) at TKO
    14. Infuse arterial catheter per medication orders
  • Medication Orders
    • Vasopressin 100 IU / 250 cc D5W (0.4 IU / cc).
      • Infuse arterial catheter at:_____ cc / hr X _____hours
      • If no evidence of GI bleeding, reduce to ______cc / hr X _____hours
      • If no evidence of GI bleeding, reduce to ______cc / hr X _____hours
      • If no evidence of GI bleeding, stop vasopressin, infuse D5W at TKO and contact Interventional Radiology

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