Vasopressin as a second agent in septic shock (May 2018)

Link to study: https://jamanetwork.com/journals/jama/fullarticle/2680546

OBJECTIVES: To determine whether treatment with vasopressin + catecholamine vasopressors compared with catecholamine vasopressors alone was associated with reductions in the risk of adverse events.

Consensus:

In patients w/distributive shock from sepsis, norepi is the agent of choice; but the optimal additive agent is unknown.

• Population: in the studies included there was 3088 patients; average at ~61.1 years, 45.% women w/distributive shock on a single agent catecholamine.

• Intervention: add vaso as second line

• Comparison: add epi/neo as second line

• Outcome:

  • Primary outcome: risk of atrial fibrillation

    • Found that afib was overall reduced

  • Secondary outcomes: mortality, requirement for RRT/AKI, myocardial injury

    • The findings varied

In this meta-analysis of 23 trials it was reported that the addition of vaso to epi/levo/other catecholamines did NOT decease mortality but it did result in a lower rate of afib.

Although not specifically studied, the protective effect of vasopresson on arrythmia is likely 2/2 reduced need for catecholamines. These results provide some support vaso as an additive agent to norepi.

Interesting Notes:

• When 9 studies were pooled, Vasoopressin + catecholamines was associated with a significant increase in digital ischemia (moderate quality evidence) - 24 more occurrences per 1000 patients

• Vasopressin may have contributed to reduction in afib by sparing the adrenergic stimulation provided by catecholaminergic vasopressors

• Limitations: unable to do subgroup analyeses, unable to permit judgement about risk of bias, did not account for differences in way vasopressors were titrated/weaned