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Extensive symmetrical skin necrosis and cutaneous blisters after vasopressin infusion in a 5-year-old child with catecholamine-resistant cold shock

Vasopressin is recommended as a rescue vasoconstrictive agent in severe pediatric vasodilatory shock. Still there are no convincing literature on the use of vasopressin in high-systemic vascular resistance shock and in pediatric cardiac arrest. The authors report a case of catecholamine-resistant cold shock developing extensive skin necrosis with multiple blisters after high-dose vasopressin use via a central venous catheter. A 5-year-old previously healthy female child presented to emergency department unresponsive with no central pulse. The child required cardiopulmonary resuscitation multiple times in pediatric ICU for intractable hyperkalemia and for mixed cardiogenic and catecholamine-resistant cold shock. Emergency hemodialysis was done, starting high-dose vasopressin to maintain cardiac perfusion. Vasodilator milrinone infusion was started after 12 h. Cardiac output gradually improved, and vasoconstrictive inotropes were weaned off on day 3. However, the child developed bilateral extensive skin necrosis and multiple bullae on both hands and foot on days 2–3, which required multiple debridements. Skin and digital perfusion then gradually improved in next 72 h avoiding the need for amputation. Vasopressin has been included in Adult Cardiopulmonary Resuscitation Guideline as a second vasopressor to epinephrine. Although vasopressin is used widely in pediatric vasodilatory shock, its use in cardiac arrest resuscitation and cold shock scenario remains questionable. Many cases of extensive skin necrosis after peripheral vasopressin extravasation have been reported in adults. In our case, vasopressin infusion was given through a central venous line. We observed that concomitant use of vasodilators may reduce skin and digital gangrenous complications of vasopressin. We conclude that vasopressin infusion should be used with extreme caution in catecholamine-refractory septic cold shock.