now let's move to vasopressin after norepinephrine and there is a reason I'm talking about this right after norepinephrine I'll show you in a second but without talking about all these receptors but there's a person's work right here in making the vessels narrower vasoconstriction no effect here is just here fewer ways of constructive capabilities which as we said this will increase a pressure and if anything it will cause decrease heart rate by reflex bradycardia no in clinical practice the only time we use visit prison is to be also in Vasil dilatory or distributive shock right the main one here is septic shock so I don't recall when was Lhasa I use it in a different indication and listen to this it's only add on agent mainly two nor epi so never use somebody with shock there's a present on its own as a first-line it's only add on and mainly add on to norepinephrine and the main thing it will do it will augment nor ap effect plus it helped us decrease nor ap require dose so one of the best thing we use it is usually once I get to use more ten mcg per minute of leave of it or nor AP and some weight but that's what I use once I get more than that I add vaso present and this is in septic shock very personally septic shock doses fixed 0.04 units it's the only visit process that we use units instead of mcg per minute and some hospital use 0.03 some hospital they titrate up and down at 0.1 but usually for septic shock we saw on 0.04 and I tell them leave it as it is don't touch it titrate down leave it I keep visit person and to live with requirement is really low less than 10 marks or even less than 5 marks this is really up to you and then get rid of vasopressin and leave Lea will fit so it helps augment the action of norepinephrine and decrease the dose required of norepinephrine which help reduce the possible side effects remember you have to have the water without this without adequate fluid resuscitation neither vasopressin or Levophed would work and remember this person needs to give in central line as all other there's a present mixed with normal saline usually it can cause extravasation and the same problem and tissue necrosis we can give phentolamine as we said in Levophed it can cause hyponatremia because at the end it is an ADH right and also one other indication outside the shock if you don't have octreotide in your hospital you can use it for it so feed you various is a bleed of course some use it to you treat diabetes insipidus but this is not our topic so that's mainly remember it's an add-on never added on its own Malee's visit the little shocked mainly septic shock mainly a second agent add on to nor epi it augments nor epi decrease the dose required of norepi it's a fixed dose usually 0.04 unit we don't titrate up down and again I use it person when I might leave a fight require more than ten marks some more than away ten to fifteen or twenty but the earlier the better to use it and again don't titrate it up and down although some do and I usually shut it off immediately now one possible problem they said if you shut it off completely you may get hypotensive but if you have leave of it there should hopefully prevent that but remember don't titrate it down titrate leave of it down to decrease lahood requirement until it becomes less than ten marks or even five months then you can shut off visitors and then shut off level fit hopefully that was useful thanks for watching this video please subscribe to our Channel and activate the notification bill secret to see the videos as soon as they are released glad to have you on board