Rhabdomyolysis associated with the use of intravenous vasopressin

A patient with acute esophageal variceal bleeding developed fatal rhabdomyolysis during treatment with a continuous intravenous infusion of vasopressin. Signs of ischemia, including mottling of skin and painful extremities, preceded the development of the characteristic electrolyte abnormalities and cardiac arrhythmias. No other recognized causes of rhabdomyolysis were identified on retrospective review of the hospital course. There are several factors which might promote a peripheral ischemic response to vasopressin in the bleeding cirrhotic patient, including altered resting hemodynamics, increased resting sympathetic tone, impaired vasodilation as a compensatory response to vasopressin, and reduced hepatic drug clearance. Idiosyncratic factors involving vasopressin receptor affinity and distribution, vasopressin-associated vasodilation in some vascular beds, and the effect of vasopressin on the renin-angiotensin system may further contribute to impaired tissue perfusion. These multiple overlapping factors probably lead to rhabdomyolysis in a minority of patients receiving vasopressin infusion.