Efficacy and Safety of the Early Addition of Vasopressin to Norepinephrine in Septic Shock

Hammond, Drayton A.; Cullen, Julia; Painter, Jacob T.; McCain, Kelsey; Clem, Oktawia A; Brotherton, Amy; Chopra, Divyan; Meena, Nikhil

doi:10.1177/0885066617725255

Cited by 36 publications

(59 citation statements)

References 13 publications

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“…One of the potential benefits from early concomitant vasopressin and norepinephrine therapy noted in this study was a decrease in the time to achieve and maintain MAP of 65 mm Hg. Similar results were observed in an observational cohort study (6.2 hrs in the combination group vs 9.9 hrs in the monotherapy group, p=0.023) that also defined maintenance of MAP to be a duration of 4 or more hours without initiation of additional vasoactive support or intravenous fluids . Conversely, a single‐center pre‐post study did not find a difference in time to achieve and maintain MAP of 65 mm Hg when patients who received norepinephrine and vasopressin were compared with patients who received norepinephrine monotherapy .…”

Section: Discussionsupporting

confidence: 76%

“…One study had a median time to addition of vasopressin to norepinephrine of 2 hours and observed a reduced incidence of new‐onset arrhythmias in the early concomitant vasopressin group (37.1%) compared with the initial norepinephrine monotherapy group (63.9%), likely due to the reduced dosage of norepinephrine in the concomitant therapy group leading to an agonistic effect at the β‐1 receptors . This finding was not corroborated in other studies or this study . In addition to the similar durations of therapy with vasopressin and norepinephrine alongside similar but relatively high maximum dosages of norepinephrine, the definition of an arrhythmia in this study was intended to identify clinically meaningful events that required intervention, which may explain the moderate rates of new‐onset arrhythmia of 15% in the early concomitant vasopressin group and 7% in the norepinephrine monotherapy group.…”

Section: Discussioncontrasting

confidence: 56%

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Prospective Open‐label Trial of Early Concomitant Vasopressin and Norepinephrine Therapy versus Initial Norepinephrine Monotherapy in Septic Shock

et al. 2018

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Section: Discussionsupporting

confidence: 76%

Section: Discussioncontrasting

confidence: 56%

Prospective Open‐label Trial of Early Concomitant Vasopressin and Norepinephrine Therapy versus Initial Norepinephrine Monotherapy in Septic Shock

et al. 2018

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“…For example, respondents were less likely to recommend vasopressin as a second‐line vasopressor to raise mean arterial pressure when cost was considered, likely reflecting the preference for a less costly option with epinephrine when the Surviving Sepsis Campaign Guideline recommendation supported either agent . However, it is notable that over two‐thirds of pharmacists still recommended vasopressin even when considering cost and lower levels of evidence, suggesting their practice bias may be influenced by strong personal beliefs regarding physiological bases for vasopressin use but a lack of or controversial supporting data . The scenarios for which there are physiological bases for vasopressin use may represent opportunities for restrictions in the short‐term and research in the intermediate‐to‐long term.…”

Section: Discussionmentioning

confidence: 99%

Perceptions regarding vasopressin use and practices in septic shock, and cost containment strategies

Hammond

Rech

Daley

et al. 2019

J Am Coll Clin Pharm

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Background Clinician preferences and practices regarding appropriate vasopressin use in light of its increased acquisition cost secondary to rebranding has not been evaluated or described since the most recent iteration of the Surviving Sepsis Campaign Guideline was published. Objective To assess vasopressin cost containment initiatives and pharmacists' opinions regarding appropriate vasopressin use. Methods A scenario‐based survey was distributed to critical care and emergency medicine pharmacists. Responses were characterized using frequency and descriptive statistics. Categorical variables between those who implemented changes (Vasopressin Cost Consideration) and those who did not (Usual Care) were compared using chi‐square or Fisher's exact tests. McNemar's test was used to compare responses in clinical scenarios between Vasopressin Cost Consideration and Usual Care groups. Results Among 1757 pharmacists surveyed, 200 (11.3%) responded. When respondents considered vasopressin cost and evidence (vs evidence alone), fewer respondents would use vasopressin adjunctively with norepinephrine (21% vs 26.6%, P = 0.031), to raise mean arterial pressure compared with epinephrine (65.2% vs 72.3%, P = 0.012), or to reduce norepinephrine infusion rates (71.4% vs 81.4%, P < 0.001), but would use with steroids (62.4% vs 28.3%, P < 0.001). Most (72%) respondents had implemented vasopressin cost containment and/or education initiatives. The Vasopressin Cost Consideration group respondents were more likely to initiate vasopressin at 0.03 units/minute without titrating (47.9% vs 33.9%, P = 0.045). Conclusion Since vasopressin was generically rebranded, most institutions have implemented at least one initiative to reduce vasopressin use and/or educate clinicians about its appropriate use. When vasopressin acquisition costs were considered, pharmacists recommended its use less frequently, particularly in clinical scenarios where its use is controversial.

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“…Vasopressin also has a “catecholamine‐sparing effect” that results in decreased catecholamine exposure and potentially decreased catecholamine‐related adverse effects . Furthermore, some small studies suggest that early initiation of vasopressin may result in faster resolution of shock and organ failure with decreased vasopressor‐related arrhythmias . The largest prospective randomized controlled trials, however, have been unable to confirm clear clinical benefits to vasopressin.…”

Section: Discussionmentioning

confidence: 99%

“…The Vasopressin vs Norepinephrine Infusion in Patients with Septic Shock (VASST) study was a large, randomized, controlled trial that compared these two therapies in septic shock resistant to low‐dose NE and found no difference in 28‐day mortality (AVP 35% vs NE 39%, P = 0.26) . Other studies, however, have demonstrated faster resolution of shock and decreased organ dysfunction when vasopressin is initiated within 4 to 6 hours of the onset of shock . Further uncertainty exists regarding the optimal order of vasopressor discontinuation …”

Section: Introductionmentioning

confidence: 99%

Utilization of vasopressin before and after protocol implementation in a surgical intensive care unit

Smith

Rumbaugh

2019

J Am Coll Clin Pharm

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Introduction Vasopressin is recommended for management of septic shock refractory to fluid challenge and norepinephrine. Controversy exists over when to add vasopressin to norepinephrine treatment. Due to the rising cost of vasopressin and the lack of mortality benefit, the surgical intensive care unit (SICU) at Vanderbilt University Medical Center implemented a protocol for vasopressin use with the purpose of decreasing utilization and cost. Objective The purpose of this study was to characterize vasopressin utilization and evaluate adherence to this protocol. Methods Through a retrospective, observational analysis, adult patients admitted to the SICU who received vasopressin during the 11 months before and after protocol implementation in August 2015 were identified. The primary outcome was vasopressin usage per patient. Secondary outcomes included norepinephrine use, vasopressin cost, and protocol adherence. Results During the pre‐ and post‐protocol periods, 144 of 1788 admitted patients (8%) and 119 of 1845 admitted patients (6%) received vasopressin, respectively. The total duration of vasopressin infusion during hospitalization was similar before and after protocol implementation (20 vs 18 hours, P = 0.526), but vasopressin was both added and discontinued when norepinephrine was infusing at a higher rate (added at 12 vs 18 mcg/min, P < 0.001; discontinued at 0.5 vs 6.0 mcg/min, P < 0.001). Norepinephrine was infused for a longer duration post protocol implementation (31 vs 57 hours, P < 0.001). After implementation, a protocol violation occurred in 59 patients (50%); however, 59% of these were related to vasopressin initiation in the operating room. Thirty‐two patients (27%) experienced a SICU‐related violation, with the most common type being discontinuation of norepinephrine prior to vasopressin. Conclusion Implementation of a vasopressin utilization protocol in a SICU resulted in more selective usage of vasopressin and a similar duration of infusion when it was utilized. Protocol adherence was nearly 75%, exposing some opportunities for continued education and improvement.

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Efficacy and Safety of the Early Addition of Vasopressin to Norepinephrine in Septic Shock

Abstract: Early initiation of vasopressin in patients with septic shock may achieve and maintain goal MAP sooner and resolve organ dysfunction at 72 hours more effectively than later or no initiation.

Cited by 36 publications

References 13 publications

Prospective Open‐label Trial of Early Concomitant Vasopressin and Norepinephrine Therapy versus Initial Norepinephrine Monotherapy in Septic Shock

Prospective Open‐label Trial of Early Concomitant Vasopressin and Norepinephrine Therapy versus Initial Norepinephrine Monotherapy in Septic Shock

Perceptions regarding vasopressin use and practices in septic shock, and cost containment strategies

Utilization of vasopressin before and after protocol implementation in a surgical intensive care unit

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