Pitressin

Generic Name: Vasopressin
Class: Pituitary
VA Class: HS702
CAS Number: 11000-17-2

Introduction

Exogenous antidiuretic hormone (ADH); maintains serum osmolality in normal range and acts as a vasopressor.b 150 152 157

Uses for Pitressin

Diabetes Insipidus

Prevention or control of polydypsia, polyuria, and dehydration in diabetes insipidus caused by a deficiency of endogenous posterior pituitary ADH (neurohypophyseal diabetes insipidus), but desmopressin usually considered drug of choice.b

May be used in the initial or emergency treatment of the disease, but, because of its short duration of action, its use is impractical for chronic therapy.154

Intranasal aqueous vasopressin may be effective for daily maintenance therapy and the degree of absorption is usually adequate to control mild diabetes insipidus; other drugs are preferred (e.g., chlorpropamide).154

Polyuria

May correct fluid imbalance associated with transient polyuria due to ADH deficiency accompanying neurosurgery or head injury.154

Not effective in controlling polyuria caused by renal disease, nephrogenic diabetes insipidus, hypokalemia or hypercalcemia, or polyuria secondary to the administration of demeclocycline or lithium carbonate.b

CPR

Used for its vasopressor effects; may give 1 dose to replace first or second dose of epinephrine in ACLS during CPR.150 152 153 157

Comparably effective to epinephrine in patients with cardiac arrest150 152 153 157 160 161 163 166 (presented with VF or pulseless electrical activity); however, conflicting evidence exists whether vasopressin is more effective than epinephrine in patients with asystolic cardiac arrest.150 152 153 157 164 165

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May enhance the probability of return of spontaneous circulation (ROSC), survival to hospital admission, as well as hospital discharge.150 152 153 157 160 161 162 164 165

Combination of vasopressin and epinephrine (if refractory) has been reported to be more effective than repeated epinephrine alone for refractory cardiac arrest;152 153 157 159 166 however, optimal timing of vasopressin administration in relation to epinephrine use during cardiac arrest not fully established (i.e., replacement of first versus second epinephrine dose).158

Abdominal Distention

To stimulate peristalsis in the prevention or relief of intestinal paresis, postoperative abdominal distention, and distention complicating pneumonias or toxemias.b

Abdominal Radiographic Procedures

To dispel interfering gas shadows and/or to concentrate the contrast media prior to abdominal radiographic procedures including IV urography, cholecystography, and kidney biopsy.154

Diagnostic Uses

Although vasopressin injection has been used as a provocative test for pituitary release of growth hormone and corticotropin, arginine hydrochloride and insulin generally are considered the most reliable diagnostic indicators of growth hormone reserve.b

GI Hemorrhage

Administered IV or intra-arterially into the superior mesenteric artery as an adjunct in the treatment of acute and life-threatening, massive GI hemorrhage caused by ruptured esophageal varices (e.g., in alcoholic cirrhotics), peptic ulcer disease, esophagogastritis, esophageal laceration, acute gastritis, colitis associated with Behcet’s disease, colonic diverticulosis, small intestinal typhoid infection, Mallory-Weiss syndrome, or intestinal perforation.b

Infused into the mesenteric artery prior to and during portosystemic shunt surgery for esophageal varices.154

May provide effective control of bleeding, but there is no evidence that the drug substantially improves overall survival.b

Should not preclude use of other measures (e.g., blood transfusions, esophageal tamponade, paracentesis, ice water gavage, sclerotherapy, emergency surgery) when indicated.154

Vasodilatory Shock

May consider for hemodynamic support as a continuous infusion in vasodilatory shock such as septic shock and sepsis syndrome, if conventional adrenergic vasopressor drugs are ineffective.150 151 157

Pitressin Dosage and Administration

General

  • May administer 1–2 glasses of water with vasopressin to reduce occurrence of adverse effects (e.g., skin blanching, abdominal cramps, nausea) and improve therapeutic response.154 155

Administration

Administer IM or sub-Q.b

May administer topically to nasal mucosa for antidiuresis; do not inhale.b

May administer IV (e.g., for ACLS during CPR, GI hemorrhage), by intraosseous injection (e.g., for ACLS during CPR) or intra-arterially (e.g., for GI hemorrhage).b 157 Although vasopressin may be administered via an endotracheal tube for ACLS during CPR, a specific dose is not established and IV or intraosseous administration is preferred because of more predictable drug delivery and pharmacologic effect.157

For solution and drug compatibility information, see Compatibility under Stability.

IM or Sub-Q Administration

Usually, administer IM or sub-Q at 3- to 4-hour intervals as needed.154

Intranasally

May be applied topically to the nasal mucosa as a spray, drops, or via a saturated pledget; the drug should not be inhaled.154

IV or Intra-arterial Administration

May administer by IV injection for ACLS during CPR.b 157

May administer by continuous IV or intra-arterial infusion (e.g., for GI hemorrhage).154

GI hemorrhage, particularly alcoholic cirrhotics: Preferably, administer initially by continuous IV infusion, since intra-arterial infusion is not more effective but is technically more difficult; patients who fail to respond adequately to initial IV infusion therapy may respond to intra-arterial infusion therapy.b

GI hemorrhage: Perform intra-arterial or IV administration only under the supervision of a clinician familiar with the pharmacologic effects of vasopressin and with all acceptable treatment modalities for GI bleeding.154

GI hemorrhage: Intra-arterial infusion requires specialized techniques, including angiographic placement of the catheter; limit to clinicians familiar with this method of administration and the management of potential complications.b

Dilution

GI hemorrhage, intra-arterial or continuous IV infusion: Generally dilute with 0.9% sodium chloride or 5% dextrose injection to a concentration of 0.1–1 unit/mL.b

Rate of Administration

GI hemorrhage: Adjust rate to response and tolerance.b

GI hemorrhage, IV infusion: Into a peripheral vein via controlled-infusion device; usually, 0.2–0.9 units/minute.b

GI hemorrhage, intra-arterial infusion: Usually, into the superior mesenteric artery via controlled-infusion device; usually, 0.1–0.5 units/minute.b

GI hemorrhage, intra-arterial infusion: Also into the splenic or celiac axis usually, 0.1–0.5 units/minute.b

Diverticular hemorrhage, intra-arterial infusion: Into the inferior mesenteric artery.b

Intraosseous Administration

For ACLS during CPR in adults, may administer by intraosseous injection; onset of action and systemic concentrations are comparable to those achieved with central venous administration.157

Dosage

Potency of vasopressin (arginine and lysine) is standardized according to pressor activity in rats and is expressed in USP posterior pituitary (pressor) units.b

Antidiuretic activity of commercially available preparations may be variable.154

Antidiuretic dosages are variable and must be adjusted according to response; to avoid adverse effects, it is desirable to give doses that are just sufficient to elicit the desired response.154 155

Adults: 10 units elicit full physiologic response; 5 units adequate in many cases.154

Pediatric Patients

Diabetes Insipidus
Neurohypophyseal
IM or Sub-Q

2.5–10 units 2–4 times daily.b

Intranasal

Individualize dosage and dosing interval according to response.b

Abdominal Distention and Abdominal Radiographic Procedures
IM

Give doses proportionately reduced from adult dose.155

Diagnostic Uses
Provocative Testing for Growth Hormone and Corticotropin Release
IM

0.3 units/kg; then obtain blood specimens and assay for hormones.b

Adults

Diabetes Insipidus
Neurohypophyseal
IM or Subcutaneous

5–10 units 2–4 times daily as needed;155 range 5–60 units daily.154

Intranasal

Individualize dosage and dosing interval according to response.b

CPR (Cardiac Arrest)
VF, Pulseless VT, Pulseless Electrical Activity, and Asystole in ACLS
IV

40 units, given as a single dose, may replace first or second dose of epinephrine.152 157

Intraosseous

40 units, given as a single dose, may replace first or second dose of epinephrine.157

Abdominal Distention and Abdominal Radiographic Procedures
Abdominal Distention
IM

Usually, 5 units; may give subsequent doses every 3–4 hours, increasing to 10 units if necessary.154 155

Dosage applies to prevention and relief of postoperative distention and other causes.155

Abdominal Radiographic Procedures
Sub-Q

5–15 units given 2 hours and repeated 30 minutes prior to abdominal radiographs and kidney biopsy (before films are exposed)155 ; usually give an enema prior to the first dose.155

Diagnostic Uses
Provocative Testing for Growth Hormone and Corticotropin Release
IM

10 units; then obtain blood specimens and assay for hormones.

GI Hemorrhage
Esophageal Varices and GI Bleeding
IV Infusion

Dosage is empiric and must be individualized according to response and tolerance.b

Because many of the adverse effects are dose related, the lowest possible effective dosage should be used.b

Usually initiate at 0.2–0.4 units/minute and progressively increase to 0.9 units/minute if necessary.b Additional benefit at higher rates unlikely.b

After 24 hours, the infusion rate should be tapered according to patient response, but administration of vasopressin has been continued for 3 days to 2 weeks.154

Intra-arterial Infusion

Dosage is empiric and must be individualized according to the response and tolerance.b

Because many of the adverse effects are dose related, the lowest possible effective dosage should be used.b

Usually, 0.1–0.5 units/minute; after 20–30 minutes, the vasoconstrictive and clotting responses to intra-arterial vasopressin can be assessed by angiography.b

Response also can be monitored with portal pressures or hepatic wedge pressures.b

After 24 hours, the infusion rate should be tapered according to patient response, but administration of vasopressin has been continued for 3 days to 2 weeks.154

Vasodilatory Shock
IV Infusion

Optimum dosage and duration remain to be established; usually, 0.02–0.1 units/minute.151

Special Populations

Hepatic Impairment

Hepatic Impairment

No specific dosage recommendations for patients with hepatic impairment.

Renal Impairment

Renal Impairment

No specific dosage recommendations for patients with renal impairment.

Geriatric Patients

No specific dosage recommendations compared to younger adults.

Cautions for Pitressin

Contraindications

  • Chronic nephritis accompanied by nitrogen retention, until reasonable nitrogen concentrations are attained.b

  • History of anaphylaxis or other hypersensitivity to vasopressin of any component in the formulation.b

Warnings/Precautions

Warnings

Diseases in Which Rapid Addition to Extracellular Fluids May Be Hazardous

Use cautiously in patients with seizure disorders, migraine, asthma, heart failure, vascular disease (especially of the coronary arteries), angina pectoris, coronary thrombosis, renal disease, goiter with cardiac complications, arteriosclerosis, or any other disease in which rapid addition to extracellular fluids may be hazardous.b

Sensitivity Reactions

Hypersensitivity

Hypersensitivity reactions characterized by urticaria, angioedema, bronchoconstriction, fever, rash, wheezing, dyspnea, circulatory collapse, cardiac arrest, and anaphylaxis.154

Appropriate agents for the treatment of hypersensitivity reactions should be readily available.154

Major Toxicities

Water Intoxication

May produce water intoxication.b

Observe closely for signs of possible development (see Monitoring under Cautions) to prevent ensuing seizures, coma, and death.b

Water intoxication may be treated with water restriction and temporary withdrawal of vasopressin until polyuria occurs.b

Severe water intoxication may require osmotic diuresis (e.g., with mannitol, hypertonic dextrose, or urea alone or with furosemide).155

Little danger with small antidiuretic doses of vasopressin to control diabetes insipidus when fluid intake is not excessive.154

Hypertonic saline solutions are not indicated unless immediate correction of hyponatremia is required.154

Cardiac Effects

In large doses, may produce increased blood pressure, bradycardia, minor arrhythmias, premature atrial contraction, heart block, peripheral vascular constriction or collapse, coronary insufficiency, decreased cardiac output, myocardial ischemia, and myocardial infarction.154

Extreme caution, if at all, in patients with vascular disease (especially of the coronary arteries), since even small doses can precipitate angina; AMI risk with large doses.154

Coronary vasodilators (e.g., amyl nitrite, nitroglycerin) may be used to treat angina if it occurs.154

An ECG should be used to monitor the hormone’s cardiac effects during IV or intra-arterial therapy.154 155

General Precautions

Polyuria

Caution in preoperative and postoperative polyuric patients, since vasopressin requirements may be considerably less than normal.b

Monitoring

Monitor fluid intake and output closely, especially in comatose or semicomatose patients.b

Monitor electrolyte balance periodically.b

Perform ECGs periodically during therapy.154

Observe for early signs of water intoxication (e.g., drowsiness, listlessness, headache, confusion, anuria, weight gain) in order to prevent ensuing seizures, coma, and death).b

Risks of Intra-arterial Administration

Risk of coronary thrombosis, mesenteric infarction, venous thrombosis, infarction and necrosis of the small bowel, and peripheral emboli resulting from intra-arterial catheterization and infusion into the superior mesenteric artery.b

Specific Populations

Pregnancy

Category C.155 a

Although doses sufficient for an antidiuretic effect are not likely to produce tonic uterine contractions that could be deleterious to the fetus or threaten the continuation of the pregnancy, use in pregnant women only when clearly needed.b

When administered in ACLS, may decrease blood flow to the uterus; however, the woman must be resuscitated for survival of the fetus.157

Lactation

Caution if used in nursing women.155

Pediatric Use

Children are particularly sensitive to vasopressin’s effects (e.g., volume/hydration disturbances); exercise caution.154

Safety and efficacy as vasopressor therapy for pediatric advanced life support (PALS) not established;150 insufficient evidence to make a recommendation for or against routine use during cardiac arrest in pediatric patients.157

Geriatric Use

Geriatric patients are particularly sensitive to vasopressin’s effects; exercise caution.154

Common Adverse Effects

Adverse effects associated with low doses are infrequent and mild, but increase in frequency and severity with high doses.154

Common adverse effects include circumoral pallor, sweating, tremor, pounding in the head, abdominal cramps, passage of gas, vertigo, nausea, vomiting, and eructation.154 In addition, diarrhea, intestinal hyperactivity, and uterine cramps may occur.154

Patients can be advised that some of these effects (e.g., blanching of the skin, abdominal cramps, nausea) may be minimized by taking 1 or 2 glasses of water at the time of vasopressin administration.154

Interactions for Pitressin

Specific Drugs

Drug

Interaction

Comments

Alcohol

May block the antidiuretic activity of vasopressin in varying degrees155 a

Antidepressants, tricyclic

May potentiate the antidiuretic response to vasopressin155 a

Carbamazepine

May potentiate the antidiuretic response to vasopressin155 a

Chlorpropamide

May potentiate the antidiuretic response to vasopressin155 a

Clofibrate

May potentiate the antidiuretic response to vasopressin155 a

Demeclocycline

May block the antidiuretic activity of vasopressin in varying degrees155 a

Epinephrine

May block the antidiuretic activity of vasopressin in varying degrees155 a

Fludrocortisone

May potentiate the antidiuretic response to vasopressin155 a

Heparin

May block the antidiuretic activity of vasopressin in varying degrees155 a

Lithium

May block the antidiuretic activity of vasopressin in varying degrees155 a

Norepinephrine

May block the antidiuretic activity of vasopressin in varying degrees155 a

Drugs blocking antidiuretic effect

May block the antidiuretic activity of vasopressin in varying degrees155

Drugs potentiating antidiuretic effect

May potentiate the antidiuretic response to vasopressin155 a

Ganglionic blocking agents

Ganglionic blocking agents may produce a marked increase in sensitivity to the hormone’s pressor effects155

Phenformin

May potentiate the antidiuretic response to vasopressin155 a

Urea

May potentiate the antidiuretic response to vasopressin155 a

Pitressin Pharmacokinetics

Absorption

Destroyed by trypsin which is found in the GI tract and, therefore, must be administered parenterally or intranasally.b

Absorption of vasopressin through the nasal mucosa is relatively poor.154

Duration

Sub-Q or IM, antidiuretic activity: Variable but effects are usually maintained for 2–8 hours.b

Plasma Concentrations

Urine isotonicity is maintained when plasma concentrations of vasopressin are approximately 1 microunit/mL, while plasma concentrations of 4.5–6 microunits/mL produce maximum concentration of urine.b

Distribution

Extent

Distributed throughout the extracellular fluid.b

Plasma Protein Binding

No evidence of plasma protein binding.b

Elimination

Metabolism

The majority of a dose is rapidly destroyed in the liver and kidneys.154

Elimination Route

Sub-Q: Approximately 5% of a dose is excreted in urine unchanged after 4 hours.154

IV: 5–15% of the total dosage appears in urine.154

Half-life

About 10–20 minutes.154 155

Special Populations

Oxytocinase, a circulating enzyme produced early in pregnancy, is capable of cleaving the polypeptide; otherwise, plasma inactivation of vasopressin is negligible.154

Stability

Storage

Parenteral

Injection

Store between 15–25°C (59° and 77°F); do not freeze.155

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Solution CompatibilityHID

Compatible

Dextrose 5% in water

Sodium chloride 0.9%

Drug Compatibility
Admixture CompatibilityHID

Compatible

Verapamil HCl156

Evaluated by pushing vasopressin through a Y-site over 5 seconds

Y-Site Compatibility HID

Compatible

Amiodarone HCl

Argatroban

Caspofungin acetate

Ceftaroline fosamil

Ciprofloxacin

Diltiazem HCl

Dobutamine HCl

Dopamine HCl

Epinephrine HCl

Fluconazole

Gentamicin sulfate

Heparin sodium

Hydroxyethyl starch 130/0.4 in sodium chloride 0.9%

Imipenem-cilastatin sodium

Insulin, regular

Lidocaine HCl

Linezolid

Meropenem

Metronidazole

Micafungin sodium

Milrinone lactate

Moxifloxacin HCl

Nitroglycerin

Norepinephrine bitartrate

Pantoprazole sodium

Phenylephrine HCl

Piperacillin sodium-tazobactam sodium

Procainamide HCl

Sodium bicarbonate

Telavancin HCl

Voriconazole

Incompatible

Furosemide

Phenytoin sodium

Actions

  • Exogenous vasopressin elicits all the pharmacologic responses usually produced by endogenous vasopressin (antidiuretic hormone);b primary physiologic role of vasopressin is to maintain serum osmolality within a normal range.154

  • Produces relatively concentrated urine by increasing reabsorption of water by the renal tubules. Its action in regulating body fluid balance is mediated by renal vasopressin V2 receptors, which are coupled to adenyl cyclase and the generation of cyclic AMP.151 At the tubular level, vasopressin stimulates adenyl cyclase activity, leading to increases in cyclic adenosine monophosphate (AMP).b Cyclic AMP increases water permeability at the luminal surface of the distal convoluted tubule and collecting duct, resulting in increased urine osmolality and decreased urinary flow rate.154

  • Conserves up to 90% of the water that might otherwise be excreted in the urine. Vasopressin also increases reabsorption of urea by the collecting ducts.b

  • Increases coronary blood flow and the availability of oxygen to the myocardium.152 153 A preferred approach in patients with asystolic cardiac arrest would be to administer vasopressin rather than epinephrine initially, reserving epinephrine for patients who do not experience ROSC with the initial vasopressin doses.152 153

  • In doses greater than those required for antidiuretic effects, vasopressin directly stimulates contraction of smooth muscle V1 receptors.b

  • The vasoconstrictive action of vasopressin is mediated by vascular V1 receptors;150 151 the vascular receptors are coupled to phospholipase C, resulting in release of calcium from sarcoplasmic reticulum in smooth muscle cells, leading to vasoconstriction.151

  • Causes vasoconstriction, particularly of capillaries and of small arterioles, resulting in decreased blood flow to the splanchnic, coronary, GI, pancreatic, skin, and muscular systems.154

  • When administered into the celiac or superior mesenteric arteries, vasopressin constricts gastroduodenal, left gastric, superior mesenteric, and splenic arteries; however, hepatic arteries are not constricted and, instead, hepatic blood flow often increases.b

  • In the intestinal tract, increases peristaltic activity, particularly of the large bowel; also causes an increase in GI sphincter pressure and a decrease in gastric secretion but has no effect on gastric acid concentration. Contraction of smooth muscle of the gallbladder and of the urinary bladder also occurs.154 a

  • Oxytocic properties of vasopressin are minimal, but in large doses the drug may stimulate uterine contraction.b The hormone also possesses slight milk ejecting properties but its role during lactation is negligible.154

  • In addition to its peripheral effects, vasopressin causes release of corticotropin, growth hormone, and follicle-stimulating hormone.154

Advice to Patients

  • Importance of alerting patients that ceratin adverse effects (e.g., blanching of skin, abdominal cramps, nausea) may be reduced by taking 1 or 2 glasses of water at the time of administration. These side effects are usually not serious and probably will disappear within a few minutes.155

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs.154

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.154

  • Importance of informing patients of other important precautionary information.a (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Vasopressin

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injection

20 units/mL*

Pitressin

Monarch

Vasopressin Injection

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions September 4, 2013. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

Only references cited for selected revisions after 1984 are available electronically.

150. The American Heart Association in Collaboration with the International Liaison Committee on Resuscitation. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2000; 102(Suppl I) I-87,I-130-1, I-143, I-145-8, I-150, I-307, I-309, I-319.

151. Rozenfeld V, Cheng WM. The role of vasopressin in the treatment of vasodilation in shock states. Ann Pharmacother. 2000; 34:250-3. [IDIS 439877] [PubMed 10676834]

152. Wenzel V, Krismer AC, Arntz H et al for the European Resuscitation Council Vasopressor during Cardiopulmonary Resuscitation Study Group. A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med. 2004; 350:105-13. [IDIS 509448] [PubMed 14711909]

153. Mcintyre KM. Vasopressin in asystolic cardiac arrest. N Engl J Med. 2004; 350:179-81. [PubMed 14711918]

154. AHFS Drug Information 2003. McEvoy, GK, ed. Vasopressin. Bethesda, MD: American Society of Health-System Pharmacists; 2003: 3050-2.

155. Monarch. Pitressin (vasopressin injection, USP) prescribing information. Bristol, TN: 1998 Jul.

156. Trissel LA. Handbook on injectable drugs. 12th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2003:1358.

157. The American Heart Association. Guidelines 2005 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2005; 112(Suppl I): IV1-211.

158. Miano TA, Crouch MA. Evolving role of vasopressin in the treatment of cardiac arrest. Pharmacotherapy. 2006; 26:828-39. [PubMed 16716136]

159. Guyette FX, Guimond GE, Hostler D et al. Vasopressin administered with epinephrine is associated with a return of a pulse in out-of-hospital cardiac arrest. Resuscitation. 2004; 63:277-82. [PubMed 15582762]

160. Lindner KH, Dirks B, Strohmenger HU et al. Randomised comparison of epinephrine and vasopressin in patients with out-of-hospital ventricular fibrillation. Lancet. 1997; 349:535-7. [PubMed 9048792]

161. Lindner KH, Prengel AW, Brinkmann A et al. Vasopressin administration in refractory cardiac arrest. Ann Intern Med. 1996; 124:1061-4. [PubMed 8633820]

162. Mann K, Berg RA, Nadkarni V. Beneficial effects of vasopressin in prolonged pediatric cardiac arrest: a case series. Resuscitation. 2002; 52:149-56. [PubMed 11841882]

163. Morris DC, Dereczyk BE, Grzybowski M et al. Vasopressin can increase coronary perfusion pressure during human cardiopulmonary resuscitation. Acad Emerg Med. 1997; 4:878-83. [PubMed 9305429]

164. Stiell IG, Hebert PC, Wells GA et al. Vasopressin versus epinephrine for inhospital cardiac arrest: a randomised controlled trial. Lancet. 2001; 358:105-9. [PubMed 11463411]

165. Aung K, Htay T. Vasopressin for cardiac arrest: a systematic review and meta-analysis. Arch Intern Med. 2005; 165:17-24. [PubMed 15642869]

166. Wenzel V, Lindner KH. Vasopressin combined with epinephrine during cardiac resuscitation: a solution for the future? Crit Care. 2006; 10:125.

a. Monarch Pharmaceuticals. Pitressin (vasopressin injection, USP) prescribing information. Bristol, TN: 1998 Jul.

b. AHFS drug information 2004. McEvoy GK, ed. Vasopressin. Bethesda, MD: American Society of Health-System Pharmacists; 2004:3070-3.

HID. Trissel LA. Handbook on injectable drugs. 17th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2013:1126-8.

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