Lets talk vasopressin

[epidural man]

So -

Background -
Vasopressin FDA approved for post-operative abdominal distension. Dose and route - FDA approved - is 10-20units IM or SQ. Not approved for IV use.
What do we know about a body with too much vassopressin? Patients with SIADH have a bunch floating around - they are not hypertensive.

We had a discussion at our hospital about ACE - I, and post induction hypotension, and the use of vassopressin. The discussion was that 2-4 units is a very large dose and shouldn't be exceeded. Others in our group totally disagreed and said it is relatively weak and much larger doses can be tolerated, is not dangerous, and larger doses probably should be used. The counter to this was in septic patients, the recommended dose is tiny. However, the counter to this is that septic patients are likely much more sensitive to the drug and doesn't compare to a 70 y/o with HTN on an ACEI who needs pressure support post propofol.

Anecdotally, a co-worker told me that yesterday, had that situation, BP was 50/30 post induction, he gave 10 units IV, BP returned to 110/80 and stayed there the whole time.

What are your practices? Any reason not to give large doses? Has anyone seen severe HTN after vassopressin?

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[Arch Guillotti]

Usually start with one-half to one unit.

 

[caligas]

Work in 10 to 20 u as adjuvant to inotropes with RV failure coming off bypass. You get bump in SVR without much increase in PAP.

 

[Planktonmd]

Patients coming off bypass should not be compared to patients with transient hypotension after induction of anesthesia.
If for some mysterious reason Vasopressin is your number one choice to reverse post induction hypotension I think it should be given in no more than 1 unit increments.
How about less induction agent?

 

[epidural man]

Patients coming off bypass should not be compared to patients with transient hypotension after induction of anesthesia.
If for some mysterious reason Vasopressin is you number one choice to reverse post induction hypotension I think it should be given in no more than 1 unit increments.

Why? have you seen problems with larger doses?

 

[risnwb]

Why? have you seen problems with larger doses?

I usually start with .5-1 unit for hypitension I believe is related to acei. I've seen patients reaction to the drug be highly variable, from minimal change in Bp to raising the systolic from 90s to ~180 with one unit. That's why I start low. Also I've heard lots of anecdotal stuff from ICU docs who claim higher doses intraop result in more frequent gut ischemia...

 

[Gas you down]

I start with 0.25 to 0.5 units. I've seen someone go from 50/30 to 170/90 with half a unit. that's coming off bypass. I use it in situations like Caligas, just smaller doses.

 

[Planktonmd]

Why? have you seen problems with larger doses?

I think that vasopressin in large doses causes severe peripheral vasoconstriction that does not contribute to improving or increasing the blood pressure, in other words once you exceed a certain dose all you get is more peripheral ischemia because of the vasoconstriction of small vessels and capillaries, that's why patients look severely pale or gray after big dose vasopressin, they actually look dead.

 

[fakin' the funk]

0.5-2 units for ACEi relalted vasoplegia. Or any vasoplegia really. Or anyone who just needs a good slug of SVR that will last longer than phenylephrine (usual duration 10-20 in my exp).

Also love it (at septic shock drip dose) with epi for RV failure. Gets SVR and MAP up, keeps that RV perfused without adding RV afterload.

10-20 unit boluses are, IMO, insane.

 

[fakin' the funk]

So -

Background -
Vasopressin FDA approved for post-operative abdominal distension. Dose and route - FDA approved - is 10-20units IM or SQ. Not approved for IV use.

A) wtf abdominal distension? What's wrong with simethicone.
B) Apparently it IS approved for IV use...as of Nov 2014.
http://www.prnewswire.com/news-rele...rict-vasopressin-injection-usp-282391581.html

 

[pgg]

Anecdotally, a co-worker told me that yesterday, had that situation, BP was 50/30 post induction, he gave 10 units IV, BP returned to 110/80 and stayed there the whole time.

That's a lot of crammed into one short sentence. I'd have to wonder about a co-worker who
a) found himself looking at 50/30 post induction in the first place
b) and then gave 10 units of IV vasopressin

 

[urge]

10-20 unit boluses are, IMO, insane.

There is a lot of insane people around. I never use it. It's just asking for trouble. Pts get clamped down. A big slug of phenylephrine will get the BP up too without any drama.

For coming off bypass with a sick heart, it makes sense. It does not make sense to make the bp look good after a less than elegant induction.

Learn to use your phenylephrine.

 

[epidural man]

0.5-2 units for ACEi relalted vasoplegia. Or any vasoplegia really. Or anyone who just needs a good slug of SVR that will last longer than phenylephrine (usual duration 10-20 in my exp).

Also love it (at septic shock drip dose) with epi for RV failure. Gets SVR and MAP up, keeps that RV perfused without adding RV afterload.

10-20 unit boluses are, IMO, insane.

That is what the package insert recommends. I know you all are smart and all, but I suspect the people that wrote the package insert and the drug manufacterer's know a thing or two about the drug as well.

 

[epidural man]

There is a lot of insane people around. I never use it. It's just asking for trouble. Pts get clamped down. A big slug of phenylephrine will get the BP up too without any drama.

For coming off bypass with a sick heart, it makes sense. It does not make sense to make the bp look good after a less than elegant induction.

Learn to use your phenylephrine.

Doesn't always work...that is the point.

On patients with on chronic ACEI or ARB, the sympathomimetics sometimes act like water. In those cases, anesthesiologist starting looking at the only other receptor left ot help increase vascular tone - V1

 

[urge]

Doesn't always work...that is the point.

Somehow I make it work.

I bet you 1 mg of phenylephrine will bring the BP up.

 

[norwood]

That is what the package insert recommends.

Seriously?!

Most vaso I've ever given was on a guy with refractory anaphylactic shock after exhausting all other treatments. And I didn't hit 10 units on him. More common was, as others have said, maybe 1 unit on sick pts who just weren't getting much of a lift out of Neo anymore. And in those guys, 1 unit was normally all it took.

Agree with pgg and urge, if BP is going to 50/30 on induction, you're doing something wrong.

 

[Noyac]

I have a couple thoughts here:
1) that BP 50/30 is common when you give too much propofol and usually will return to a more respectable number shortly. So anything would have given the result your colleague described.
2) I have never given more than about 15 u in a single case much less 10u at one time. I start with 1u, maybe I should start lower but I've never seen the dramatic response some are describing here. It is possibly because I never start with vasopressin as my first line treatment. If I'm giving vaso then others maneuvers have failed or I just need some adjunct to what I'm giving.
3) I think it is a good drug but not all that impressive unless used in conjunction with others.

 

[epidural man]

Seriously?!

Seriously, that is what it says.

 

[caligas]

Work in 10 to 20 u as adjuvant to inotropes with RV failure coming off bypass. You get bump in SVR without much increase in PAP.

To clarify: 10, 20 u max titrated in slowly in the post bypass period after initiation of other pressors and inotrope drips.

 

[Urzuz]

Somehow I make it work.

I bet you 1 mg of phenylephrine will bring the BP up.

Why is 1 mg of phenylephrine any better than 0.5-1 unit of vasopressin? Both constrict blood vessels, both can lead to bad complications if you give it into a blown IV...and in fact, phenylephrine will cause pulmonary arterial vasoconstriction as well...? Not saying that bolusing vasopressin doesn't have its problems, but not sure what you would be accomplishing but pushing 1 mg of phenylephrine at a time to spare your patient a 0.5 unit push of vasopressin.

 

[urge]

Why is 1 mg of phenylephrine any better than 0.5-1 unit of vasopressin? Both constrict blood vessels, both can lead to bad complications if you give it into a blown IV...and in fact, phenylephrine will cause pulmonary arterial vasoconstriction as well...? Not saying that bolusing vasopressin doesn't have its problems, but not sure what you would be accomplishing but pushing 1 mg of phenylephrine at a time to spare your patient a 0.5 unit push of vasopressin.

Veno constriction vs arterial constriction.

Have you seen A lines stop working after vasopressin? I have. Multiple times. I haven't seen it with phenylpehrine. I'm sure the same happens in the gut and the kidney when you bolus it.

 

[norwood]

Seriously, that is what it says.

OK, going back to your original post, you were saying that the IM or SQ dosing is what they recommended - right? I didn't refer back to that first post and was reading subsequent postings as saying that 10 units IV was recommended by the manufacturer.

IMHO 10 units SQ or IM is also a silly way of giving it, but at least doesn't seem quite so acutely dangerous as 10 units IV.

 

[sevoflurane]

IMHO 10 units SQ or IM is also a silly way of giving it, but at least doesn't seem quite so acutely dangerous as 10 units IV.

Are people really doing this? Geesh.

I've given IM ephedrine before and altough it works, it's a dirty way of giving a pressor and you loose your ability to titrate it.

 

[norwood]

Are people really doing this?

I'm not. I don't see the point of giving a pressor via a route other than IV.

I've given IM ephedrine before and altough it works, it's a dirty way of giving a pressor and you loose your ability to titrate it.

Completely agree. Yeah, I tried that looooong ago after I had an attending who swore it helped with post-spinal nausea. It did, sorta kinda, at first, but basically just by blunting the BP drop a bit.

 

[Urzuz]

Veno constriction vs arterial constriction.

Have you seen A lines stop working after vasopressin? I have. Multiple times. I haven't seen it with phenylpehrine. I'm sure the same happens in the gut and the kidney when you bolus it.

I haven't seen an arterial line stop working after a 0.5-1 unit bolus of vasopressin, but then again, I'm new to practice and don't have too many years of experience under my belt yet. How many units were being given in these boluses that flat-lined the A-line? I hope not like code dose 40 unit boluses!

Phenylephrine does constrict vessels on the arterial side though (mostly arterioles...the "resistance" vessels)...that's the reason why phenylephrine-soaked pledgets stuffed in the nose act as effective decongestants and will lead to less bleeding with instrumentation of the nose (just like cocaine), and the reason why extravasated phenylephrine leads to badness.

Which is more likely to cause end-organ ischemia due to arterial vasoconstriction though -- 0.5 units of vasopressin or 1 mg of phenylephrine? I don't know the answer to that. But maybe I can learn something here

 

[Noyac]

I've given IM ephedrine before and altough it works, it's a dirty way of giving a pressor and you loose your ability to titrate it.

One of my favorite tricks, next to the syringe of neo in the IV bag for c/s.
If I place an epidural for s surgical case I always use it. But like everyone knows, it's sometimes difficult to use the epidural along with a GA without having to support the BP. Well, you can't really send the pt to the floor with neo in the IV bag so whatcha gonna do? I inject about 30mg of ephedrine in the shoulder at the end of the case and nobody ever knows. BP stays in a reasonable range and I never get a call.

 

[Planktonmd]

Are people really doing this? Geesh.

I've given IM ephedrine before and altough it works, it's a dirty way of giving a pressor and you loose your ability to titrate it.

Ephedrine IM is a good way to take your hypotensive spinal anesthetic patient to PACU and avoid multiple PACU phone calls.
I give the whole amp (50mg)

 

[urge]

I haven't seen an arterial line stop working after a 0.5-1 unit bolus of vasopressin, but then again, I'm new to practice and don't have too many years of experience under my belt yet. How many units were being given in these boluses that flat-lined the A-line? I hope not like code dose 40 unit boluses!

Phenylephrine does constrict vessels on the arterial side though (mostly arterioles...the "resistance" vessels)...that's the reason why phenylephrine-soaked pledgets stuffed in the nose act as effective decongestants and will lead to less bleeding with instrumentation of the nose (just like cocaine), and the reason why extravasated phenylephrine leads to badness.

Which is more likely to cause end-organ ischemia due to arterial vasoconstriction though -- 0.5 units of vasopressin or 1 mg of phenylephrine? I don't know the answer to that. But maybe I can learn something here

You need to do more cases.

You are comparing a small dose of vaso to a truck load of phenylephrine like they both will give you 120/80. That wasn't my point. My point was to give larger doses of phenylephrine if needed. I doubt also half an unit of vaso will bring bp from 50 to 120, btw.

You have to make up your mind. Either you say phenylephrine doesn't work, and hence 1mg is nothing, or you accept you were giving too low doses for the patient. You cannot say it doesn't work but 1mg will cause ischemia because it suddenly works too well. Doing so, you are making my point.

 

[Urzuz]

You need to do more cases.

You are comparing a small dose of vaso to a truck load of phenylephrine like they both will give you 120/80. That wasn't my point. My point was to give larger doses of phenylephrine if needed. I doubt also half an unit of vaso will bring bp from 50 to 120, btw.

You have to make up your mind. Either you say phenylephrine doesn't work, and hence 1mg is nothing, or you accept you were giving too low doses for the patient. You cannot say it doesn't work but 1mg will cause ischemia because it suddenly works too well. Doing so, you are making my point.

Hey now, no need to get confrontational...we are just having a discussion. In any event, go back and reread what I wrote. When did I ever say that 1 mg of phenylephrine wouldn't work? I simply asked, what are you accomplishing by pushing 1 mg of phenylephrine at a time versus giving a 0.5 unit bolus of vasopressin. As others have mentioned on this thread and has been well described in anesthesia literature, patients on ACEis and ARBs just don't always respond "normally" to vasoconstrictors such as phenylephrine.

And for the record, I have firsthand seen 0.5-1 unit of vasopressin raise the SBP from the pits up to the 120s in patients on ACEis and ARBs who weren't responding to escalating doses of phenylephrine. Granted these patients already had phenylephrine floating around in their system, and before going to vasopressin I wasn't pushing 1 mg of phenylephrine at a time.

 

[epidural man]

both can lead to bad complications if you give it into a blown IV...and in fact, phenylephrine will cause pulmonary arterial vasoconstriction as well...? Not saying that bolusing vasopressin doesn't have its problems, but not sure what you would be accomplishing but pushing 1 mg of phenylephrine at a time to spare your patient a 0.5 unit push of vasopressin.

Some points - Vassopressin will NOT cause problems with a blown IV. you can give 20 units safely SQ. That is why it is so safe - much safer than other vasoconstricters given peripherally.

Second - vassopressin relaxes pulmonary vasculature - as well as other vascular beds in the body.

Finaly, serum levels are the same if you give it IV or IM or SQ - only difference is onset.

The feelings of many on this board mimics many of those in my practice - that is - they feel that it is a very potent vasoconstricter and feel like 1 unit is very powerful and that much more than this approaches scary territory.

After looking at this, doing some reading, and talking - I still find it very strange that the makers of the drug which include the vast history of its use in medicine feel otherwise and that 20 units seem to be very safe. I just don't know who to believe...it's so confusing. Should I believe a few anonymous poster on a forum who have used it a few times and now claim expertise or believe the makers of the drug with years and years of experience? ugh. what to do...what to do.

Parenthetically, 30 minutes ago, the gyn surgeon injected 20units during our case into the very vascular area of the cervice before their vaginal hysterectomy. I asked them why they didn't use another agent - and they said because vassopressin wasn't extreme and other agents will cause necrosis. Who believes gyn anyway.

 

[BLADEMDA]

Wow,

I've given Vasopressin hundreds of times in select situations and always start with 1 unit IV push. ZERO issues with 1 unit. Since I reserve Vasopressin for refractory hypotension in the O.R. the minimum effective dose is usually more than 1 unit but that is where I start to be on the safe side.

 

[BLADEMDA]

To date, at least 5 clinical trials have demonstrated that patients on chronic ACEI/ARB undergoing general anesthesia, respond to exogenous vasopressin derivatives with an increase in blood pressure and fewer hypotensive episodes.6,7Typically, a 0.5-1 unit bolus of AVP is administered to achieve a rise in mean arterial pressure.4 The subsequent recommended infusion dose is 0.03U/min for AVP and 1-2 mcg/kg/h for terlipressin. Caution should be used as V1 agonists have been associated with the following deleterious effects: reduction in cardiac output and systemic oxygen delivery, decreased platelet count, increased serum aminotransferases and bilirubin, hyponatremia, increased pulmonary vascular resistance, decrease in renal blood flow, increase in renal oxygen consumption, and splanchnic vasoconstriction. Ischemic skin necrosis has been reported after peripheral intravenous administration through an infiltrated intravenous line.

1. Lange M, Aken HV, Westphal M. Role of vasopressinergic V1 receptor agonists in the treatment of perioperative catecholamine-refractory arterial hypotension.Best Practice & Research Clinical Anesthesiology 2008;22:369-381.
2. Coriat P, Richer C, Douraki T, et al. Influence of chronic angiotensin-converting enzyme inhibition on anesthetic induction. Anesthesiology 1994;81:299-307.
3. Ertmer C, Rehberg S, Westphal M. Vasopressin analogues in the treatment of shock states: potential pitfalls. Best Practice & Research Clinical Anaesthesiology2008;22:393-406.

 

[GA8314]

1-2 units at a time. My go to is neo, and ephedrine though. Vaso for refractory cases, thought at my gig (new) they use it much more than I did in my training.

 

[epidural man]

Ischemic skin necrosis -

Only in cases where patients are in severe shock (very different patient than post induction slump with a patient on ACEI) and also had other vassopressors going. Also, only with infusions.

However, even when studied - it doesn't seem to appear that vassopressin, in rather large doses, changes vascular resistance to the skin and it isn't an indepedent risk factor for skin necrosis.

http://www.ncbi.nlm.nih.gov/pubmed/...s+as+a+complication+of+continuous+vasopressin
http://www.ncbi.nlm.nih.gov/pubmed/...iglycyl-lysine-vasopressin+(terlipressin+INN,

Second case of the day today - Gyn folks injected over 20 units into the uterus (that is like IV actually) - no change in BP, no change in skin color or cap refill. Amazing....

 

[fakin' the funk]

Second case of the day today - Gyn folks injected over 20 units into the uterus (that is like IV actually) - no change in BP, no change in skin color or cap refill. Amazing....

Our gyn folks routinely use dilute vaso solutions on the cervix and lower uterus for various procedures. I think they put 20 units in 100ml and inject around 5-20 ml. So not a big dose. But I can't recall there being any BP effect in the cases I've done so far (not that many).

 

[Urzuz]

Some points - Vassopressin will NOT cause problems with a blown IV. you can give 20 units safely SQ. That is why it is so safe - much safer than other vasoconstricters given peripherally.

Second - vassopressin relaxes pulmonary vasculature - as well as other vascular beds in the body.

Finaly, serum levels are the same if you give it IV or IM or SQ - only difference is onset.

The feelings of many on this board mimics many of those in my practice - that is - they feel that it is a very potent vasoconstricter and feel like 1 unit is very powerful and that much more than this approaches scary territory.

After looking at this, doing some reading, and talking - I still find it very strange that the makers of the drug which include the vast history of its use in medicine feel otherwise and that 20 units seem to be very safe. I just don't know who to believe...it's so confusing. Should I believe a few anonymous poster on a forum who have used it a few times and now claim expertise or believe the makers of the drug with years and years of experience? ugh. what to do...what to do.

Parenthetically, 30 minutes ago, the gyn surgeon injected 20units during our case into the very vascular area of the cervice before their vaginal hysterectomy. I asked them why they didn't use another agent - and they said because vassopressin wasn't extreme and other agents will cause necrosis. Who believes gyn anyway.

1 - Vasopressin has been implicated in tissue necrosis caused by infusion it through a blown IV. Most of the cases are in patients with septic shock (which is probably because it is one of the more common conditions that actually warrants a vasopressin infusion), but they exist nonetheless. In fact, if an IV blows that has vasopressin in it, many places recommend treatment with alpha-blockade in hopes that it will vasodilate the vasculature and prevent necrosis. Anyway, I think we would all agree that infusing anything through a blown IV isn't a good idea, even saline.

2 - Yes, the point I was making to urge was that phenylephrine constricts the pulmonary arterial vasculature in addition to the systemic vasculature, whereas vasopressin spares pulmonary vascular constriction.

3 - interesting, did not know about the serum levels being equivalent between the different methods of delivery!

 

[Planktonmd]

When you inject an agent that causes vasoconstriction anywhere other than IV this agent limits it's own absorption by causing a local vasoconstriction.
This is why you can inject epinephrine SC or IM without causing major rise in BP and HR.
Why is that so difficult to understand?

 

[sevoflurane]

I'm not a big fan of IM anything if it can be given IV. I like the ability to titrate. I use IM ketamine the most, but that's usually in the combative patient w/o an IV. As I said, IM ephedrine works, but it certainly isn't my cup of tea. The exception is an occasional healthy OB patient with a hypotensive response to a spinal.

Turthfully, I don't have much need for IM pressors with spinals or epidurals in my practice because I don't drop off hypotensive patients in the pacu. Things are figured out by that time (w/o IM pressors). If I do find a need for a pressor I just tell the pacu nurses to start a neo drip. Easy cheese. CEA's come to mind as do Pheo's. I'd never choose ephedrine IM over a good neo drip. Even with a GA hip w/ spinal or plain spinal hip. My patient population is not that predictable (sick, old, PVD, low EF, ect). I'd keep 'em in pacu until things get better if need be. I like to monitor these patients on the phone with nursing during the next case and in between caes.

I don't like the floor nursing at my previous gig... this may be part of my issue, but still not a big fan of IM anything when I have an IV. The big question is are you masking a bleed with an IM dose? You can pick that up pretty easily with increasing IV pressor requirements in pacu before a handoff and work that patient up. Picked up a hand full of bleeds this way. I just don't trust floor nurses.
It is the main reason I like to stick to titrated pressors.

Again, IM ephedrine is fine on some patients. But for the most, it's dirty IMO. I like to see my pressor cc/min. go down before D/C.

 

[sevoflurane]

FWIW, I've never given IM vasopressin. If it comes to that, I have a feeling you should be giving it IV... but maybe I'm missing something? Maybe some SDN members that actually routinely give IM vasopressin can give their experience. I'd be curious as to how much and why.

 

[Planktonmd]

FWIW, I've never given IM vasopressin. If it comes to that, I have a feeling you should be giving it IV... but maybe I'm missing something? Maybe some SDN members that actually routinely give IM vasopressin can give their experience. I'd be curious as to how much and why.

IM or SC vasopressin is given by surgeons or GYN for other indications and it usually causes little or no pressor effect because the systemic absorption is very slow due to the local vaso constriction.
I don't think anyone gives IM Vasopressin as a pressor.

 

[sevoflurane]

Gotcha plank. just wondering if some are giving it IM for hypotension. Looking at the above posts it seems that this may have been implied. Prolly just reading into things.

 

[Ipassgas]

I like vasopressin. After failing phenylephrine, I gave 2 units to start once. BP went to 230/180. I'm sticking with my 0.5-1 to start with from here on out. 20u IV sounds . . .scary. Don't think I'd trust it SC either, and I'd never put it in a line I know is infiltrated. Actually, I'd never put anything in a line I know is infiltrated.

 

[Cytarabine]

Dumb student question - what's the deal with ACEi's/ARB's and pressors that keeps getting mentioned? Not sure if I'm forgetting some basic physiology

 

[deleted171991]

Dumb student question - what's the deal with ACEi's/ARB's and pressors that keeps getting mentioned? Not sure if I'm forgetting some basic physiology

Patients who take their ACEI/ARB on the day of surgery can have a severe hypotension, refractory to catecholamine treatment, after induction of general anesthesia. It was suggested that the hypotension is more responsive to vasopressin than to phenylephrine and/or ephedrine.

http://www.apsf.org/newsletters/html/2012/spring/12vasoplegic.htm

"To date, at least 5 clinical trials have demonstrated that patients on chronic ACEI/ARB undergoing general anesthesia, respond to exogenous vasopressin derivatives with an increase in blood pressure and fewer hypotensive episodes. Typically, a 0.5-1 unit bolus of AVP is administered to achieve a rise in mean arterial pressure. The subsequent recommended infusion dose is 0.03U/min for AVP and 1-2 mcg/kg/h for terlipressin. Caution should be used as V1 agonists have been associated with the following deleterious effects: reduction in cardiac output and systemic oxygen delivery, decreased platelet count, increased serum aminotransferases and bilirubin, hyponatremia, increased pulmonary vascular resistance, decrease in renal blood flow, increase in renal oxygen consumption, and splanchnic vasoconstriction. Ischemic skin necrosis has been reported after peripheral intravenous administration through an infiltrated intravenous line."

 

[Cytarabine]

Interesting, thanks!

 

[dhb]

Actually, I'd never put anything in a line I know is infiltrated.

Ketamine?

 

[Libertas]

Ketamine?

....insulin pump?

 

[HollywdAnesth]

? I inject about 30mg of ephedrine in the shoulder at the end of the case and nobody ever knows.

Why not inject it into the buttocks or quad after the spinal goes in? Patient doesn't feel it.

 

[Noyac]

I

Why not inject it into the buttocks or quad after the spinal goes in? Patient doesn't feel it.

I was talking about belly cases with an epidural and a GA.
I do crawl under the drapes and stick in the thigh if they are awake. Just like when I give methergine in c sections.

 

[Ipassgas]

Ketamine?

Well, you got me. But I'd probably go IM in that scenario. Though I can conceive of a situation where I'd do it.