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

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

doi:10.1002/phar.2105

Cited by 52 publications

(61 citation statements)

References 21 publications

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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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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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“…A recent prospective open‐label study evaluated if early concomitant AVP administration in patients with septic shock reduced the time to reach and maintain a MAP compared with NE alone . Patients receiving early AVP (0.04 units/min) and NE achieved a MAP of 65 mm Hg earlier than patients with NE alone; however, this difference failed to reach statistical significance (5.7 hrs vs 7.6 hrs, respectively; p=0.058).…”

Section: Arginine Vasopressin and Terlipressinmentioning

confidence: 99%

Catecholamine Vasopressor Support Sparing Strategies in Vasodilatory Shock

et al. 2019

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Shock syndromes are associated with unacceptably high rates of mortality in critically ill patients despite advances in therapeutic options. Vasodilatory shock is the most common type encountered in the intensive care unit. It is manifested by cardiovascular failure, peripheral vasodilatation, and arterial hypotension leading to tissue hypoperfusion and organ failure. Hemodynamic support is typically initiated with fluid resuscitation strategies and administration of adrenergic vasopressor agents in nonresponsive patients to restore arterial pressure with subsequent adequate organ reperfusion. Unfortunately, high catecholamine dosing requirements may be necessary to achieve targeted hemodynamic goals that may increase the risk of vasopressor‐induced adverse events. The purpose of this article is to review the clinical efficacy and safety data and potential role in therapy for catecholamine‐sparing agents in vasodilatory shock. Adjunctive therapeutic options to reduce vasoactive support requirements without compromising arterial pressure include arginine vasopressin and analogs, corticosteroids, midodrine, methylene blue, and angiotensin II. Although concomitant vasopressin and corticosteroids have a more defined role in evidence‐based guidelines for managing shock, clinicians may consider other potential catecholamine‐sparing agents.

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

Cited by 52 publications

References 21 publications

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

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

Catecholamine Vasopressor Support Sparing Strategies in Vasodilatory Shock

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

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