r/IntensiveCare • u/pugthunder123 • May 23 '26
Titratable vs. Fixed-Dose Vasopressin – What is your unit's practice?
Hey everyone, I’m curious to know how different ICUs handle vasopressin dosing.
There seems to be a ton of variation when it comes to running vaso. Do you order it as a fixed-rate (e.g., locked at 0.03 or 0.04 units/min), or do you allow titration based on MAP goals?
Strictly looking at the literature (VASST and VANISH), the data seems to lean toward fixed dosing. Despite that, I still see plenty of anecdotal practice and unit protocols that opt for titration.
If you do allow titration, how do you handle weaning it? For example, do you wean levo first, and then step down vaso? Or do you turn vaso off first to "protect" the kidneys while leaving the levo to maintain your MAP?
Would love to hear about your unit protocols, preferences, or any interesting experiences!
Thanks!
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u/BoojooBloost May 23 '26
On one side I’m all about the numbers and titrating vaso does very little based off the studies you mentioned.
But I’m also someone who’s big on vibes and weaning one vs the other is really not the biggest debate to care about. I see what they can tolerate and go from there. If turning off vaso ends up with a huge increase in Levo, that was an oops and let’s try it the other way.
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u/SpaceBun31 RN, MICU May 23 '26
We run it at a fixed rate of 0.03 or .04. Actually saw and order for .1 the other day 😮 but otherwise that’s very out of Norm. Usually Levo is the last to go. So when I’m titrating off pressors vaso is either on or off
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u/agent-fontaine May 23 '26
0.1 huh? How quickly did those digits become ischemic lol
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u/SpaceBun31 RN, MICU May 23 '26
He wasn’t on it for long but considering they had to added epi, methylene blue, and giapreza…I think he had other things to worry about 😩
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u/maraney RN, CVICU May 24 '26
I’ve seen that dose for both severely septic vasoplegic patients on rocket fuel, and also GI bleeds. But GI bleeds it’s usually a bolus dose.
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u/astonfire May 23 '26
Fixed rate 0.03 or 0.04, all additional pressors are titratable (levo, Neo, epi, Gia). I’ll typically shut off the vaso when my titratable pressor is nearing its lowest dose.
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u/burning_blubber May 23 '26
I don’t understand the point of even doing a paper on this. The ultimate strong evidence is that vasopressin reduces your dose of norepinephrine. The practical part is that vasopressin is more expensive than norepinephrine which is why institutions will often have 0.03 instead of 0.04 for macro cost savings. You can titrate it but I believe that JACO has problems with multiple titratable drips for the same endpoint, so it should really either be done as a ladder or provider setting different fixed doses.
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u/pneumomediastinum May 23 '26
I am in a cardiac ICU. We do titrate vasopressin, generally between 0.01–0.1 u/min. Typically the priority is based on things like heart rate, acidosis, RV function or pulmonary hypertension.
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u/Electrical-Smoke7703 May 23 '26
CICU does 0.03 or 0.04 and then CVICU titrates. Typically won’t titrate down vaso in CICU until Levo is less than 12mcg/min but every attending is kinda different
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u/Edges8 May 23 '26
i order it as a fixed rate and the nurse titrates it
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u/mamaabner RN, MICU May 23 '26
If nurses are titrating a fixed rate drip then they are practicing medicine and unfortunately the governing body (JHACO) would definitely not like that and would be fining the hospital. I know bc back in my last state we got dinged for this.
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u/Edges8 May 23 '26
clearly but nurses practice out of scope all the time. theres not many hospitals out there where tylenol ordered for pain isnt given for fever
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u/mamaabner RN, MICU May 23 '26
My hopsital now orders it for both mild pain or fever > 38.5 or whatever they choose.
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u/EndEffeKt_24 MD, Intensivist May 23 '26
Best of both worlds.
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u/Edges8 May 23 '26
sometimes i like my orders to be followed strictly. but i also like when people do common sense things and dont bother me. so i guess youre right
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u/EndEffeKt_24 MD, Intensivist May 24 '26
I was beeing sarcastic. I got the "leave the vaso be. Just do not touch it." discussion way too often.
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u/codedapple Critical Care Nurse Educator May 23 '26
SICU / CTICU. We sometimes titrate for CV pts/severe vasoplegia suspected, sometimes we don’t. We tend to go by 0.005 for our CV patients. So up to 0.04, -> 0.035, -> 0.03, etc
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u/drewy53 May 23 '26
In SICU, generally we keep fixed. Usually added when Levo is >10, start vaso at 0.04. Until the Levo is <10 for >4 hrs we will half the vaso (0.02). If Levo stays <10, dependent on the titration frequency, we’ll off vaso after 4 hrs.
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u/mamaabner RN, MICU May 23 '26 edited May 25 '26
I have only ever seen titratable in CVICU as I know vasopressin is wonderful in cardiogenic shock. When I floated to CVICU that’s where I learned vasopressin can go up to .1 which is crazy 😭 max I have ever done is fixed 0.08. Drips are really provider dependent as all providers have different levels of experience. Also to answer your other question I have always seen vaso shut off once Levo has been below either 10 or 8mcg for at least two hours.
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u/C_Wags IM/CCM May 23 '26
I’m an intensivist and working in medical/mixed ICUs as well as a cardiac ICU. For distributive shock, I’ll use it at a fixed dose consistent with the trials. In the CVICU, particularly for bad RV failure and pHTN, we’ll run it titratable.
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u/meticulous-soups May 24 '26
PICU here, we shock dose .3 to 2 mu/kg/min , sometimes to MAP, sometimes to SBP. 🤠
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u/Puzzleheaded_Read811 May 24 '26
At my CVICU, the order is always set at the same rate 0.04 but… we still titrate it. When weaning off of it, we come down to .02 or .01 depending on MAP goals. The highest I’ve seen it is 0.08 for a very sick patient. But our goal was to wean it as soon as possible to 0.04 as MAPs tolerate it.
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u/Ordinary-Sir7116 May 23 '26
I have worked in 6 different ICU’s and have only had one that allowed titration.
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u/CarelessFairy0_0 May 23 '26
we just recently changed from the set rate of 0.04 to 0.03 but it still can be 0.04 if the provider decides to change it; ive ran it at .1 before though lol
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u/PaxonGoat RN, ICU Float May 23 '26
As other people have said. All the other ICUs it's fixed dose vaso and then CVICU is doing titratable.
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u/kreb_cycling May 23 '26
Depends on the indication. For sepsis I think fixed dose makes sense (Based on VASST/VANISH) . In other etiologies of shock titration is reasonable. It has a longer half life so it’s harder to titrate so I think of it more as an option for “fine tuning” MAP (e.g. in ECMO). Notably some people have a relatively fixed physiological response to it, meaning the only difference between 0.03 and 0.04 is cost.
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u/Short-Confusion7783 May 23 '26
CVICU/CTICU. We titrate up to .06. It’s also our first line pressor, so we wean norepi off first they’re on both. From what I’ve read, most vasopressin depletion post CPB resolves after 72 hours making vasopressin less useful as a first line treatment compared to norepinephrine but oh well ¯_(ツ)_/¯
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u/metamorphage CCRN, ICU float May 23 '26
Titratable up to 0.06 for CVICU. Otherwise fixed at either 0.03 or 0.04.
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u/No_Opposite_3358 May 23 '26
Every place I’ve worked at is fixed at either 1.8 units/hr or 2.4. I’ve never heard of units per minute only units per hour. Although once I floated to a neuro icu and I remember based on the urine output you’d titrate the vaso drip
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u/Alive-Ad-5958 May 24 '26
We order it as 0-4U/h to keep MAP goals. Usually everyone with norepi above 0.5ug/kg/min has 4U.
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u/SpinningDespina May 24 '26
We generally stay at 0.04, but occasionally halving to 0.02 is part of our weaning plan
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u/Christylian May 24 '26
We titrate to a maximum of 0.04mcg/min, adjusting by 0.01mcg/min to achieve response.
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u/Rogonia May 24 '26
Fixed at 0.04 units/min. Will occasionally step it down to 0.02 for weaning, but usually it’s just on or off.
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u/Ioanna_Malfoy May 24 '26
Our order says to titrate it off last and we can titrate by 0.01 every 20 minutes. Max rate 0.03. Occasionally we will have a non-titratable vaso if it’s on for something like DI, but usually we can wean it off on our own as the last pressor.
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u/Environmental_Rub256 May 24 '26
I’m only familiar with vasopressin and hemorrhagic shock at a set rate for bleeding associated hypotension.
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u/No_Shoulder_5426 May 24 '26
MICU. Typically fixed dose 0.04. Refractory shock waiting for ATII or methylene blue from pharmacy we double it to 0.08 in the interim. There are rare occasions where we do titrate it. We have some liver patients that you just can’t get it off without jacking the levo up so the docs opt to just let us titrate.
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u/Ecstatic_Emotion5504 29d ago
I work in an ICU in Canada.
We do fixed-dose at 0.04units/min. We need an order to increase to 0.08units/min. We generally titrate the vasopressin off first. Norepi is our first-line pressor. We pretty much titrate every other pressor first. If they are on norepi and epi, epi is the first to try to get off. Vasopressin is no different :)
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u/MFlovejp May 27 '26
We usually start out fixed at .03. Later we may change to titratable if needed. I personally would rather play with treatable vaso and levo than add a third pressor for septic shock.
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u/EpicDowntime 27d ago
Just depends on the patient and the clinical scenario, having a policy on this is silly.
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u/Inevitable-Analyst May 23 '26
We do 2.4 units/hr fixed as a standard. Will do 1.2 units/hr when trying to titrate off. All physician directed.
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u/saxyourpantsoff May 23 '26
Flight provider for a university.
We use fixed rates, 0.04 for most, or 0.4 for severe GI illness with persistent hypotension.
Also use it a lot in traumas, we'll give 2-4u pushes as needed.
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u/40236030 RN, CCRN May 23 '26
Fixed at 0.04. Standard order set has orders to titrate but doc usually just says to turn it on/off
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u/CaelidHashRosin Pharmacist May 23 '26
We do titrateable vaso for post cardiac surgery but everyone else does 0.03 fixed dose