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Consultant, Department of Pediatric Intensive Care Medicine, Neonatology and Neuropediatrics, University Children's Hospital, Building 9, 66421, Homburg, Germany, fax 49(0)6841-1628542, sascha.meyer{at}uniklinik-saarland.de
Published Online, June 9, 2009. www.theannals.com, DOI 10.1345/aph.1L199a
Terlipressin is a synthetic analog of arginine vasopressin (AVP) and has a similar pharmacodynamic profile but a significantly longer half-life (6 h vs 6 min for AVP).3,4 AVP acts via vascular V1 receptors and renal tubular V2 receptors. V1 receptor stimulation causes arterial vasoconstriction, and V2 stimulation increases renal free water reabsorption.4
As hemodynamic profiles may change in children with catecholamine-refractory shock, in part as a result of treatment, I caution against the use of terlipressin and recommend the use of AVP as an alternative rescue drug that allows for rapid adjustment of cardiocirculatory support.4,5 AVP can be administered as a continuous infusion and easily titrated to a dosage that will restore systemic arterial blood pressure.5
More importantly, Matok et al. demonstrated significant improvement in cardiovascular parameters following the administration of terlipressin. This is in contrast to my experience using vasopressin in neonates with catecholamine-resistant shock and low cardiac output.5 Despite a transient improvement of mean arterial blood pressure and urine output, the use of vasopressin was invariably associated with an increase in lactic acidosis and poor outcome (death). Notwithstanding the potential of reversing peripheral vasoplegia via V1 receptor stimulation, terlipressin has no direct beneficial effects on left ventricular function. As a matter of fact, one would imagine that an increase in peripheral vascular resistance in children with extremely low cardiac output will result in further cardiac compromise. Given the paucity of clinical data regarding the use of terlipressin and vasopressin in children, more clinical research (ideally, randomized controlled trials) is needed to better define the indications for these therapeutic agents.
References
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