Predictors of response to fixed-dose vasopressin in adult patients with septic shock

Abstract

BackgroundVasopressin is often utilized for hemodynamic support in patients with septic shock. However, the most appropriate patient to initiate therapy in is unknown. This study was conducted to determine factors associated with hemodynamic response to fixed-dose vasopressin in patients with septic shock.MethodsSingle-center, retrospective cohort of patients receiving fixed-dose vasopressin for septic shock for at least 6 h with concomitant catecholamines in the medical, surgical, or neurosciences intensive care unit (ICU) at a tertiary care center. Patients were classified as responders or non-responders to fixed-dose vasopressin. Response was defined as a decrease in catecholamine dose requirements and achievement of mean arterial pressure ≥ 65 mmHg at 6 h after initiation of vasopressin.ResultsA total of 938 patients were included: 426 responders (45%), 512 non-responders (55%). Responders had lower rates of in-hospital (57 vs. 72%; P < 0.001) and ICU mortality (50 vs. 68%; P < 0.001), and increased ICU-free days at day 14 and hospital-free days at day 28 (2.3 ± 3.8 vs. 1.6 ± 3.3; P < 0.001 and 4.2 ± 7.2 vs. 2.8 ± 6.0; P < 0.001, respectively). On multivariable analysis, non-medical ICU location was associated with increased response odds (OR 1.70; P = 0.0049) and lactate at vasopressin initiation was associated with decreased response odds (OR 0.93; P = 0.0003). Factors not associated with response included APACHE III score, SOFA score, corticosteroid use, and catecholamine dose.ConclusionIn this evaluation, 45% responded to the addition of vasopressin with improved outcomes compared to non-responders. The only factors found to be associated with vasopressin response were ICU location and lactate concentration.

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

“…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. These areas included vasopressin use in patients with severe acidemia, low serum lactate concentration, vasopressin as initial monotherapy, and those at risk for renal failure …”

Safe Use of Vasopressin and Angiotensin II for Patients with Circulatory Shock

“…These findings were corroborated in two subsequent studies yet appeared to be limited to patients who received AVP doses of 0.067 units/minute and those receiving CRRT . However, recent evaluations did not observe increased bilirubin concentrations after AVP initiation, even when doses up to 0.067 units/minute were studied . These discrepant findings suggest that monitoring for increased bilirubin concentration after AVP initiation is warranted, but baseline bilirubin concentration should not affect the decision to initiate AVP.…”

“…However, in clinical studies, AVP was not associated with AKI or failure. In fact, recent clinical studies found that AVP may have positive effects on renal function and was shown to reduce the risk of progression of AKI and the need for continuous renal replacement therapy (CRRT) . However, these effects may be driven by a reduction in serum creatinine and increased urine output with AVP that may influence the decision to initiate CRRT.…”

“…Studies evaluating the effects of AVP on platelet count have contradictory results, however. Several evaluations showed decreased platelet count after the initiation of AVP, and others found no difference in platelet count . One evaluation found that decreased platelet count from baseline after AVP initiation was limited to patients requiring CRRT, and no difference in platelet count was observed in patients who did not require CRRT .…”

“…Precision medicine within the arena of sepsis treatment and vasopressor management may entail selecting patients for certain vasopressors based on their underlying characteristics and implementation of prediction algorithms for response or ADR to prescribed vasopressor therapy. A recent study evaluated predictors of response to fixed‐dose AVP among adult patients with septic shock utilizing EMR data . In this study of adult patients who received AVP in conjunction with catecholamines (initiated at least 1 hr before AVP), the factors independently associated with response to AVP included nonmedical ICU location and lower lactate concentrations.…”