Comparison of Norepinephrine and Terlipressin vs Norepinephrine Alone for Management of Septic Shock: A Randomized Control Study

Abstract

A bstract Purpose To compare norepinephrine and terlipressin vs norepinephrine alone for management of septic shock. Materials and methods In this prospective, randomized control trial, 50 adult patients with septic shock were randomized into two groups. Group I received a combination of injection terlipressin 0.02 µg/kg/min (fixed dose) infusion and injection norepinephrine 0.01 µg/kg/min infusion and group II received injection norepinephrine 0.01 µg/kg/min infusion alone. Dose of noradrenaline in both the groups was titrated to achieve the target MAP of 65–70 mm Hg. The data collected were the dose of norepinephrine required to maintain an MAP of above 65 mm Hg, urine output, serum lactate, procalcitonin level, C-reactive protein, sequential organ failure assessment (SOFA) score, total duration of vasopressor support, and incidences of the adverse effects. Results The norepinephrine dose in group I vs group II at 12 hours was found to be 0.141 ± 0.067 vs 0.374 ± 0.096 µg/kg/min ( p ≤0.005). The serum lactate was lower, and urine output was higher in group I than group II ( p <0.05). Group I had a significantly greater reduction in SOFA score in 12 hours than group II. Group I patient also had a significant decrease in the duration of vasopressor administration than group II patients being discharged from the ICU. However, there was no difference in the mortality between the two groups during their ICU stay. Conclusion A low-dose continuous infusion of terlipressin and norepinephrine could help attain early resuscitation goals for managing patients with septic shock. How to cite this article Sahoo P, Kothari N, Goyal S, Sharma A, Bhatia PK. Comparison of Norepinephrine and Terlipressin vs Norepinephrine Alone for Management of Septic Shock: A Randomized Control Study. Indian J Crit Care Med 2022;26(6):669–675.

Emerging concepts in the care of patients with cirrhosis and septic shock

“…Although the results of the VASST[ 73 ] and VANISH[ 74 ] trials did not demonstrate that the early use of vasopressin improved mortality or renal outcomes, respectively, low-dose vasopressin remains the agent of choice after norepinephrine in septic shock because of its relatively favorable side-effect profile and possible pleiotropic effects[ 75 ]. Though it may be reasonable to consider vasopressin analogues such as terlipressin in some patients with cirrhosis, there is currently insufficient data to support their use over vasopressin[ 76 - 78 ]. The efficacy of new non-catecholamine based vasopressors such as angiotensin II might be limited in the setting of cirrhosis as hypoalbuminemia was a negative predictor for response in the ATHOS-3 trial[ 79 ].…”

Terlipressin Combined With Norepinephrine in the Treatment of Septic Shock: A Systematic Review

“…On the other hand, when TP binds to the V2 receptor, it enhances the water reabsorption capability of the renal collecting duct cells, thereby exerting an antidiuretic effect. It is worth noting that TP exhibits a greater selectivity for V1 receptors compared with V2 receptors (12,13). The activation of both V1 and V2 receptors by TP allows for simultaneous vasoconstrictor and antidiuretic effects to occur (16,17).…”

“…Synergistic effect: TP and NE exert their effects through different mechanisms of action. TP primarily acts as a vasoconstrictor by stimulating the V1 receptor on vascular epithelial cells (12,13). On the other hand, NE increases cardiac contractility and HR and induces vasoconstriction by stimulating adrenergic receptors (32), When these two agents are combined, their effects on raising blood pressure are mutually enhanced through a synergistic effect.…”

Molecular detection of Leishmania in dermal tissue: Case control study

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“…The number of new cases of cutaneous leishmaniasis that were reported in Iraq in 2020 was rather high overall. This indicates a significant increase when compared to the elevated instances that were recorded in 2021, which demonstrates that there has been a discernible trend toward an increase over the course of the last decade [3]. The number of cases of cutaneous leishmaniasis that were documented in Iraq in the year 2020 was much greater than in the years that came before.…”