Norepinephrine and Vasopressin Compared With Norepinephrine and Epinephrine in Adults With Septic Shock

Abstract

Background: The optimal adjuvant vasopressor to norepinephrine in septic shock remains controversial. Objective: To compare durations of shock-free survival between adjuvant vasopressin and epinephrine. Methods: A retrospective, single-center, matched cohort study of adults with septic shock refractory to norepinephrine was conducted. Patients receiving norepinephrine not at target mean arterial pressure (MAP; 65 mm Hg) were initiated on vasopressin or epinephrine to raise MAP to target. Vasopressin-exposed patients were matched to epinephrine-exposed patients using propensity scores. Mortality outcomes were examined using multivariable Poisson regression with robust variance estimation. Results: Of 166 patients, 96 (entire cohort) were included in the propensity score–matched cohort. Shock-free survival durations in the first 7 days were similar between epinephrine- and vasopressin-exposed patients in the matched cohort (median = 13.2 hours, interquartile range [IQR] = 0-121.0, vs median = 41.3 hours, IQR = 0-125.9; P = 0.51). Seven- and 28-day mortality rates were similar in the matched cohort (7-day: 47.9% vs 39.6%, P = 0.35; 28-day: 56.3% vs 58.3%, P = 0.84). Mortality rates were similar between epinephrine- and vasopressin-exposed patients in propensity score–matched regression models with and without adjustments at 7 (relative risk [RR] = 1.28, 95% CI = 0.92-1.79; RR = 1.21, 95% CI = 0.81-1.81) and 28 days (RR = 1.04, 95% CI = 0.81-1.34; RR = 0.96, 95% CI = 0.69-1.34). Conclusion and Relevance: Shock-free survival durations were similar in matched epinephrine- and vasopressin-exposed groups. Adjuvant epinephrine or vasopressin alongside norepinephrine to raise MAP to target requires further investigation.

Clinical approach to vasoplegia in the transplant patient from the Pediatric Heart Transplant Society

“…Norepinephrine provides some degree of coronary vasodilatation through its ß‐adrenergic receptor agonism which may otherwise benefit the newly transplanted heart. Overall, however, caution should be exercised when using catecholamines in transplanted patients 25–28 Calcium Chloride Infusion: Calcium regulation is vitally important in the maintenance of both myocardial contractility and vasomotor tone.…”

“…Overall, however, caution should be exercised when using catecholamines in transplanted patients. [25][26][27][28] 5. Calcium Chloride Infusion: Calcium regulation is vitally important in the maintenance of both myocardial contractility and vasomotor tone.…”

Alternatives to norepinephrine in septic shock: Which agents and when?

“…In patients with septic shock, epinephrine has been compared with norepinephrine (CAT study), [ 27 ] norepinephrine and dobutamine (CATS study), [ 28 ] and vasopressin. [ 29 ] Although epinephrine use was never associated with reduced mortality, [ [27] , [28] , [29] ] shorter time to hemodynamic success, or faster weaning from vasopressors, [ 27 , 28 ] it was associated with more frequent lactic acidosis [ 27 , 28 ] and arrhythmias, [ 27 ] leading to its discontinuation in 13% of patients. [ 27 ] Epinephrine-induced lactic acidosis is a well-known metabolic effect [ 30 , 31 ] of the activation of β2-adrenergic receptors located on the surface of the skeletal muscle cells.…”

How‐to guide for effectively performing and coordinating multicenter observational research as a clinical pharmacist

“…The importance of engaging a biostatistician or an individual with significant statistical expertise, preferably from classical training in biostatistics and/or epidemiology, at this step in the process cannot be overstated. Their expertise will increase the likelihood that appropriate methods are used and data are collected in a useable manner and increase the chances of grant funding and publication success . These individuals are more accessible than many researchers may realize.…”