Association of vasopressors with mortality in critically ill patients with COVID-19: A systematic review and meta-analysis

Abstract

Purpose: The effect of vasopressors on mortality of critically ill patients with COVID-19 has not been studied extensively. Methods: A systematic search of PubMed, Scopus, and clinicaltrials.gov was conducted for relevant articles until January 2022. Eligibility criteria were randomized controlled and non-randomized trials. The primary outcome was all-cause mortality at 28 days or 30 days. The quality of studies was assessed using the MINORS tool. Paired meta-analysis was used to estimate the pooled risk ratios along with their 95% Confidence Interval. Results: In total, 33 studies were included. Twenty-one studies with a total population of 7900 individuals provided data on mortality. Patients who received vasopressors were statistically significantly more likely to die compared to those who did not receive vasopressor therapy [RR (95%CI): 4.26 (3.15, 5.76); p<0.001]. This result remained statistically significant regardless of the in-hospital setting. In-hospital and 30-day mortality were statistically significantly higher in patients who received vasopressors [RR (95%CI): 4.60 (2.47, 8.55); p<0.001 and RR (95%CI): 2.97 (1.72, 5.14); p<0.001, respectively]. Four studies provided data on specific vasopressors; the highest mortality rate was observed in patients treated with vasopressin or epinephrine, while patients receiving angiotensin-II as a sole or second-line vasopressor agent had the lowest mortality rate. Also, analysis of 10 studies with a total population of 3519 individuals revealed that patients who received vasopressors were statistically significantly more likely to experience acute kidney injury [RR (95%CI): 3.17 (2.21, 4.54); p<0.001]. Conclusion: Vasopressors have detrimental effect on survival of critically ill patients with COVID-19.

Demographics and outcomes of hemoglobin genotype in hospitalized patients with COVID‐19 and sickle cell disease in the United States

“…The increased odds of in‐hospital mortality with shock and vasopressor use in our study are consistent with the findings in a meta‐analysis where higher in‐hospital mortality, 30‐day mortality, and frequency of acute kidney injury were associated with vasopressors used in the management of shock in critically ill patients with COVID‐19 22 . Putative reasons for increased mortality risk include vasopressors' complex multi‐systemic biologic effects, which may adversely affect survival 23,24 .…”

“…12 However, in a study by Bernit et al, 13 there was no signifi- Patients with HbSS are more prone to hemolysis and severe anemia; 16 The increased odds of in-hospital mortality with shock and vasopressor use in our study are consistent with the findings in a meta-analysis where higher in-hospital mortality, 30-day mortality, and frequency of acute kidney injury were associated with vasopressors used in the management of shock in critically ill patients with COVID-19. 22 Putative reasons for increased mortality risk include vasopressors' complex multi-systemic biologic effects, which may adversely affect survival. 23,24 Also, patients with shock requiring vasopressors are usually very sick and unstable with an elevated risk of inhospital mortality.…”

Thirty-Day readmissions among COVID-19 patients hospitalized during the early pandemic in the United States: Insights from the Nationwide Readmissions Database

“…Also, there is significant in-hospital mortality associated with circulatory shock and vasopressor dependence among COVID-19 patients. 34 , 35 …”

Targeting the mammalian target of rapamycin pathway in neurological manifestations of Covid‐19

“…To diminish this inflammation driven by cytokine storms, the mTOR antagonist tocilizumab has been employed. A study has linked its usage to a remarkably reduced duration of vasopressor support in severe Covid‐19 patients 109 . While these findings are encouraging, further clinical investigations are necessary to establish tocilizumab's role as a potential therapeutic option for Covid‐19.…”