where,how and how much should be use

1. Safe Use Of Vasopressin In
Pelvic Surgeries

2. Dr Sushila Saini
• Director Jaipur doorbeen hospital & JDH
healthcare training institute, the center of
excellence for Gynae endoscopic surgery & training
• President, association of Gynae laparoscopic
surgeon of Rajasthan
• Faculty Ethicon institute of surgical excellence [J&J]
• Organizing secretory for Raj Endo Gynae
2015,2016 & 2017
• Running regular fellowship & masters courses for
Gynae lap surgery training

3. • Intramyometrial vasopressin:
Anesthesiologists’ nightmare
Disappearance of Pulse oximetry waveforms and readings with hypotension but
with regular electrocardiogram and steady end-tidal carbon dioxide

5. Vasopressin Is A Uterotonic
In The Nonpregnant Uterus
• secreted from the posterior pituitary gland.
• A nanopeptide
• regulates
– plasma volume,
– blood pressure,
– osmolality
• It causes vasoconstriction by acting through the
vasopressin (V1) receptor and exerts its
antidiuretic action through the V2 receptor in the
kidney.

8. What Is An Optimal Dose
And Dilution?
• Use the lowest that is efficacious.
• diluted with saline as 10-20 units of vasopressin for
every 100 ml of saline, making the solution in the
range of 0.1 to 0.2 U/mL . Avoid concentrations >1
U/mL . Don’t exceed a total dosage of injection
approximately 5 units. Using a solution of 0.1 U/mL,
the maximum injection is 50 mL

9. video presentationssonu kumari
vasopressin.mp4

10. How To Use?
• Single insertion is sufficient in most cases.
Multiple sites will cause the injected saline to
ooze out from the previous punctures and to
achieve the effect of aqua-dissection with
saline and vasopressin.
• the color of uterus finally changes from pink
to marble white.

11. • video presentationsRajbala vasopressin.mp4

12. THE ADVANTAGES
• Provides bloodless field
– No requirment to use energy source, simple scissors
are sufficient for dissection.
– about 45-60 min via vasoconstriction which is
sufficient for the myometrial suturing.
• Aquadissection
– The saline and vasopressin solution follows the path
of least resistance and enters the plane between the
myometrium and the myoma, which helps in easy
enucleation of myoma.
– Reduced chances of endometrial avulsion; in cases of
intramural myomas with a submucus component.

13. • video presentationsvasopressin 1.mp4

14. • REDUCED BLOOD LOSS: Usual 300-400 ml of
blood loss is reduced to less than 100 ml.
• EASY SUTURING OF MYOMETRIAL DEFECT: as the
field is very clear due to almost no bleeding.
surgeon is not an hurry to put heamostatic suture
• BETTER TISSUE HEALING,
• BETTER SCAR INTEGRITY AND
• LESS CHANCES OF SCAR DEHISCENCE.
– As no energy source is used for cutting or coagulation,
no dead or scarred tissue is left behind.

15. POSSIBLE COMPLICATIONS
• BRADYCARDIA AND/OR CARDIAC ARREST.
– Occasionally
– Be cautious in a patient with established coronary
artery or myocardial disease.
• PULMONARY OEDEMA
• SUDDEN RISE IN BLOOD PRESSURE,
– if it is accidentally injected directly into a blood vessel.
– can be avoided by simply aspirating before injecting

16. THE CARDIAC EFFECT OF
VASOPRESSIN-
• Myocardial vessel constriction may mimic
transient myocardial ischemia. This will
manifest as ST segment depression on ECG
monitoring. This may last for up to 20 min, till
the effect of vasopressin wears off.
• Sometimes, severe transient peripheral
vasoconstriction occurs with the use of
vasopressin. In this case, pulse oximeter may
not show proper reading for a short period

17. Using vasopressin?
How to Reduce the risk of adverse effects?
• Vitals Alert the anesthesiologist and the
surgical team before you inject vasopressin, so
that they are vigilant for changes in vital signs.
• Don’t inject if vitals are unstable.
• Injection Double-check that you are not
injecting into a blood vessel.

18. Maximum Safe Limit
• Dosage Don’t exceed a total dosage of
approximately 5 units.
• Solution Dilute the vasopressin in the range of 0.1
to 0.2 U/mL. Avoid concentrations >1 U/mL.
• Using a solution of 0.1 U/mL, the maximum
injection is 50 mL.
• Repeat dose.
– Repeat injection, 45 to 60 minutes after the first, may
be safe.

19. Insufflation
• The pneumo-peritoneum increase the risk of
bradycardia.
• The combined pneumo-peritoneum and
intravascular injection of vasopressin is likely
to increase the risk of cardiovascular changes.

20. Does your patient smoke or use a
nicotine replacement medication?
• Be especially cautious about the possible
synergistic effect that nicotine plus
vasopressin may have on vasoconstriction.

22. Take Home Massage
• The results indicate that vasopressin is effective in
preventing blood loss and reducing the need for
blood transfusion during myomectomy.
• Safe use of vasopressin depends upon the
surgeon’s knowledge of its pharmacodynamics
and use of safe practices.
• Care should be taken to avoid intravascular
injection; before injecting, the surgeon should pull
back on the plunger of the syringe to check for
blood.
• However, complications may result even if
intravascular injection does not occur.

23. • The maximal safe dose of vasopressin is not well established.
Cardiovascular complications following intramyometrial injection
have been reported in isolated cases with total vasopressin doses
ranging from 5 to 11 units.
• A classic prospective cohort study found no cardiovascular
complication in 13 women undergoing myomectomy who received
a maximum of 4 units of intramyometrial vasopressin.
• An upper limit of a cumulative total vasopressin dose per procedure
of 4 to 6 units has been proposed. Use of a dilute solution helps to
limit the total dose. For example,
– if we dilute 20 units of vasopressin[1 amp ] in 100 ml of saline; 4 to 6
units of vasopressin is equal to 20 to 30 mL of this solution.
– if we dilute 20 units of vasopressin[1 amp ] in 200 ml of saline; 4 to 6
units of vasopressin is equal to 40 to 60 mL of this solution

24. • Vasopressin use during myomectomy has been
associated with rare cases of bradycardia,
cardiovascular collapse, and death.
• Vasopressin use may be contraindicated in
women with medical comorbidities (eg,
cardiovascular, vascular, or renal disease).
• The use of vasopressin to decrease blood loss
during myomectomy has not been approved by
the United States Food and Drug Association

25. CONCLUSION
• No surgical procedure in medical science is
more gratifying than one finished successfully
with minimal blood loss, with the surgical field
as unspoiled at the end as it was at the
beginning. Vasopressin has a role in attaining
this ideal, but it should be used in dilution and
at a low total dosage.