Narrative Review of Controversies Involving Vasopressin Use in Septic Shock and Practical Considerations

Hammond, Drayton A.; Ammar, Mahmoud

doi:10.1177/1060028020901521

Cited by 7 publications

(5 citation statements)

References 69 publications

(181 reference statements)

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“…There is variability in vasopressor administration for hypotensive patients in the intensive care unit (ICU), and trials on vasopressors have been inconclusive. [55][56][57] Vasopressor usage is therefore an interesting potential target for medical decision models. Vasopressor use in the inpatient setting can impact a patient greatly, and the onset of action is often in minutes.…”

Section: Research Objectivementioning

confidence: 99%

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Relative sparsity for medical decision problems

Weisenthal

Thurston

Ertefaie

2023

Statistics in Medicine

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Existing statistical methods can estimate a policy, or a mapping from covariates to decisions, which can then instruct decision makers (eg, whether to administer hypotension treatment based on covariates blood pressure and heart rate). There is great interest in using such data‐driven policies in healthcare. However, it is often important to explain to the healthcare provider, and to the patient, how a new policy differs from the current standard of care. This end is facilitated if one can pinpoint the aspects of the policy (ie, the parameters for blood pressure and heart rate) that change when moving from the standard of care to the new, suggested policy. To this end, we adapt ideas from Trust Region Policy Optimization (TRPO). In our work, however, unlike in TRPO, the difference between the suggested policy and standard of care is required to be sparse, aiding with interpretability. This yields “relative sparsity,” where, as a function of a tuning parameter, λ$$ \lambda $$, we can approximately control the number of parameters in our suggested policy that differ from their counterparts in the standard of care (eg, heart rate only). We propose a criterion for selecting λ$$ \lambda $$, perform simulations, and illustrate our method with a real, observational healthcare dataset, deriving a policy that is easy to explain in the context of the current standard of care. Our work promotes the adoption of data‐driven decision aids, which have great potential to improve health outcomes.

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Section: Research Objectivementioning

confidence: 99%

“…There is variability in vasopressor administration for hypotensive patients in the intensive care unit (ICU), and trials on vasopressors have been inconclusive 55‐57 . Vasopressor usage is therefore an interesting potential target for medical decision models.…”

Section: Real Data Analysismentioning

confidence: 99%

Relative sparsity for medical decision problems

Weisenthal

Thurston

Ertefaie

2023

Statistics in Medicine

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“…Similar findings were later observed in two retrospective studies. 8,9 In 2018, a single-center prospective trial among patients with septic shock sought to determine whether early concomitant vasopressin and NE treatment (vasopressin initiated within four hours of NE) reduced time to achieve and maintain target MAP compared with NE monotherapy. 10 While the median time to achieve and maintain MAP occurred faster in the combination group (5.7 h vs 7.6 h; p = 0.058), the outcome was not statistically significant.…”

Section: Introductionmentioning

confidence: 99%

Vasopressin Initiation as a Second-Line VasoPressor in Early Septic Shock (VISPSS)

Ragoonanan,

Nickelsen,

Tran

et al. 2023

J Intensive Care Med

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Background Vasopressin is recommended as a second-line vasoactive agent for the management of septic shock; however, a paucity of data to guide its optimal use remains. The aim was to evaluate the effect of time-to vasopressin initiation and norepinephrine (NE) dose at vasopressin initiation on clinical outcomes in patients presenting with septic shock. Methods This was a multi-centered, retrospective, observational study conducted in patients with septic shock. Patients were divided into 2 groups: patients initiated on vasopressin when NE-equivalent dose (NEE) < 0.25 mcg/kg/min or ≥ 0.25 mcg/kg/min. The primary outcome was time-to-vasopressor discontinuation (hours). Secondary outcomes included 28-day in-hospital mortality, intensive care unit (ICU) length of stay (LOS), fluid balance after 72 hours, and the change in NEE at 12 hours. Results A total of 302 patients were included in this study. After propensity-score matching, 73 patients in each group were identified for analysis. There was no significant difference in the time-to-vasopressor discontinuation (hours) between the groups (88.8 [55–187.5] vs 86.7 [47–172]); p = 0.7815). Fluid balance (mL) at 72 hours was significantly lower when vasopressin was initiated at NEE < 0.25 mcg/kg/min (1769 [71–7287] vs 5762 [1463–8813]; p = 0.0077). A multivariable linear regression showed shorter time to shock resolution with earlier vasopressin initiation, defined as within 4 hours (p < 0.05). Conclusion In this propensity-score matched cohort, vasopressin initiation at NEE < 0.25 mcg/kg/min was not associated with shorter vasopressor duration. There was a lower fluid balance at 72 hours when vasopressin was initiated at lower NE doses.

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Section: Introductionmentioning

confidence: 99%

“…Several other clinical dilemmas exist regarding the optimal use of AVP including patient body weight, 9,10 AVP dose, 11 and AVP-corticosteroid interactions, 12 which proposes a challenge for clinicians in identifying patients likely to benefit from its use. 13 Furthermore, the presence of acidosis may also favor the use of AVP given that vasopressin receptor sensitivity is somewhat preserved in an acidic environment compared to adrenergic receptors. 14 Several retrospective studies have attempted to identify patient-specific factors associated with responsiveness to AVP therapy, with differing definitions of what constitutes responsiveness, 15,16 however these studies either included patients with other forms of shock (ie cardiogenic) or did not classify patients on the most recent iteration of the Surviving Sepsis Campaign guidelines.…”

Section: Introductionmentioning

confidence: 99%

Influence of Timing and Catecholamine Requirements on Vasopressin Responsiveness in Critically ill Patients with Septic Shock

Jakowenko

Murata

Kopp

et al. 2022

J Intensive Care Med

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Introduction: Despite its widespread use, there is a paucity of data to guide the optimal use of arginine vasopressin (AVP) in critically ill patients with septic shock. Methods: This multicenter retrospective cohort study conducted in critically ill adults sought to evaluate the role of catecholamine requirements and timing on responsiveness to AVP. Responsiveness was defined as both a decrease in ≥ 50% of catecholamine requirements and no decrease in mean arterial pressure (MAP) at 4 hours post-AVP initiation. Primary outcomes of interest included the proportion of patients who started AVP within 4 hours after starting catecholamine therapy, as well as baseline norepinephrine (NE) equivalents (< 15, 15-39, or ≥ 40 mcg/min). Multivariate analyses and logistic regression were performed to identify other factors associated with AVP responsiveness. Results: There were 300 patients included in this study, with 74 patients being responders and 226 being non-responders. There was no significant difference in the number of patients who received AVP within 4 hours from catecholamine initiation between responders and non-responders (35% vs. 42%, P = 0.29). There were more patients in the non-responder group requiring ≥ 40 mcg/min of NE equivalents at AVP initiation (30% vs. 16%, P = 0.023). Stress dose steroid use was less common in responders (35% vs. 52%, P = 0.011), which was consistent with logistic regression analysis (OR 0.56, 95% 0.32-0.98, P = 0.044). Clinical outcomes between responders and non-responders were similar, apart from ICU (5.4% vs. 19.5%) and hospital (5.4% vs. 20.4%) mortality being lower in responders (P = 0.0032 and P = 0.0002, respectively). Conclusion: Shorter times to AVP initiation was not associated with responsiveness at 4 hours post-catecholamine initiation, although non-responders tended to require higher doses of NE equivalents at time of AVP initiation. Concomitant corticosteroids were associated with a lower likelihood of AVP responsiveness.

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Narrative Review of Controversies Involving Vasopressin Use in Septic Shock and Practical Considerations

Cited by 7 publications

References 69 publications

Relative sparsity for medical decision problems

Relative sparsity for medical decision problems

Vasopressin Initiation as a Second-Line VasoPressor in Early Septic Shock (VISPSS)

Influence of Timing and Catecholamine Requirements on Vasopressin Responsiveness in Critically ill Patients with Septic Shock

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