Do You Titrate Vasopressin?

Compared to catecholamine infusions which are routinely titrated, there’s a polarized practice with vasopressin – those who titrate and those who don’t. As a resident, I worked with intensivists who strongly believed in “0.04 U/min or nothing at all.” They believed that similar to electrolyte repletion, vasopressin at this fixed dose (used in many studies) addressed a deficiency in the critically ill population beyond which there was no additional benefit. Torbic et al. showed that even adjusting vasopressin for weight/BMI in septic shock did not change MAP or concurrent catecholamine infusion doses. So maybe a fixed dose is enough? 

Transitioning to a different medical center, I saw more cardiac anesthesiologists and intensivists titrating vasopressin anywhere from 0.01 to 0.10 units/minute. There are plenty of vasopressin titration protocols one can look up online and which have also been used in studies to achieve a mean arterial pressure goal. I’ve also bolused vasopressin after coming off cardiopulmonary bypass and in trauma with associated acidosis with very good results. But are higher doses safe?

I can’t find any studies directly addressing the question of fixed dose versus titrated vasopressin. Intuitively, one would think that a higher dose (0.10 U/min) would activate more V1 receptors causing more vasoconstriction. But could this, in turn, cause more ill effects like digital ischemia?

What do you all do at your respective institutions? Is there literature in favor of a specific practice? Drop me a comment with your experiences!