Does Vasopressin Exacerbate Cerebral Edema in Patients with Severe Traumatic Brain Injury?

• Published in: The American surgeon 2018-01, Vol.84 (1), p.43-50
• Main Authors: Allen, Casey J., Subhawong, Ty K., Hanna, Mena M., Chelala, Lydia, Bullock, M. Ross, Schulman, Carl I., Proctor, Kenneth G.
• Format: Article
• Language: English
• Subjects: Adult; Argipressin; Brain; Brain Edema - diagnosis; Brain Edema - drug therapy; Brain Edema - etiology; Brain Edema - mortality; Brain Injuries, Traumatic - complications; Brain Injuries, Traumatic - diagnosis; Brain Injuries, Traumatic - drug therapy; Brain Injuries, Traumatic - mortality; Catecholamines; Catecholamines - therapeutic use; Cerebrovascular Circulation - drug effects; Critical care; Edema; FDA approval; Female; Head injuries; Humans; Hypertension; Hypotheses; Intensive care; Intracranial pressure; Male; Mannitol; Mercury; Middle Aged; Mortality; Neurosurgery; Osmotic pressure; Patients; Perfusion; Pressure; Retrospective Studies; Sepsis; Sodium chloride; Substantia alba; Surgeons; Therapy; Tomography; Trauma; Trauma Severity Indices; Traumatic brain injury; Treatment Outcome; Vasoconstrictor Agents - administration & dosage; Vasoconstrictor Agents - adverse effects; Vasopressin; Vasopressins - administration & dosage; Vasopressins - adverse effects
• ISSN: 0003-1348; 1555-9823
• DOI: 10.1177/000313481808400121

Arginine vasopressin (AVP) is often used as an alternative pressor to catecholamines (CATs). However, unlike CATs, AVP is a powerful antidiuretic that could promote edema. We tested the hypothesis that AVP promoted cerebral edema and/or increased requirements for osmotherapy, relative to those who received CATs, for cerebral perfusion pressure (CPP) management after traumatic brain injury (TBI). This is a retrospective review of 286 consecutive TBI patients with intracranial pressure monitoring at a single institution from September 2008 to January 2015. Cerebral edema was quantitated using CT attenuation in prespecified areas of gray and white matter. Results: To maintain CPP >60 mm Hg, 205 patients required no vasopressors, 41 received a single CAT, 12 received AVP, and 28 required both. Those who required no pressors were generally less injured; required less hyperosmolar therapy and less total fluid; and had lower plasma Na, lower intracranial pressure, less edema, and lower mortality (all P < 0.05). Edema; daily mean, minimum, and maximum Na levels; and mortality were similar with AVP versus CATs, but the daily requirement of mannitol and 3 per cent NaCl were reduced by 45 and 35 per cent (both P < 0.05). In patients with TBI who required CPP therapy, AVP reduced the requirements for hyperosmolar therapy and did not delay resolution or increase cerebral edema compared with CATs.