The Vasopressin Loading for Refractory septic shock (VALOR) study: a prospective observational study - PubMed (original) (raw)

Observational Study

The Vasopressin Loading for Refractory septic shock (VALOR) study: a prospective observational study

Kensuke Nakamura et al. Crit Care. 2023.

Abstract

Background: Vasopressin is a second-line vasoactive agent for refractory septic shock. Vasopressin loading is not generally performed because of the lack of evidence for its effects and safety. However, based on our previous findings, we hypothesized it can predict the responsibility to vasopressin infusion with safety, and prospectively examined it in the present study.

Methods: Vasopressin loading was performed via the intravenous administration of a bolus of 1 U, followed by its continuous infusion at 1U/h in patients with septic shock treated with ≥ 0.2 μg/kg/min noradrenaline. An arterial pressure wave analysis was conducted, and endocrinological tests were performed immediately prior to vasopressin loading. We classified patients into responders/non-responders based on mean arterial pressure (MAP) changes after vasopressin loading. Based on our previous findings, the lower tertile of MAP changes was selected as the cut-off. The change in the catecholamine index (CAI) after 6 h was assigned as the primary outcome. Digital ischemia, mesenteric ischemia, and myocardial ischemia during the admission period were prospectively and systematically recorded as adverse events.

Results: Ninety-two patients were registered during the study period and examined. Sixty-two patients with a MAP change > 22 mmHg were assigned as responders and the others as non-responders. Blood adrenocorticotropic hormone levels were significantly higher in non-responders. Stroke volume variations were higher in responders before loading, while stroke volume and dP/dtmax were higher in responders after loading. Median CAI changes were - 10 in responders and 0 in non-responders, which was significantly lower in the former (p < 0.0001). AUROC of MAP change with vasopressin loading to predict CAI change < 0 after continuous infusion was 0.843 with sensitivity of 0.92 and specificity of 0.77. Ischemia events were observed in 5 cases (5.4%).

Conclusions: Vasopressin loading may be safely introduced for septic shock. Vasopressin loading may be used to predict responses to its continuous infusion and select appropriate strategies to increase blood pressure.

Keywords: Bolus; Critical care; Loading; Sepsis; Septic shock; Vasopressin.

© 2023. The Author(s).

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Conflict of interest statement

We declare that we have no competing interests related to this manuscript or the study.

Figures

Fig. 1

Fig. 1

Study outline

Fig. 2

Fig. 2

Changes in the catecholamine index in responders/non-responders to vasopressin loading. Responders to vasopressin loading were defined by a mean arterial pressure change > 22 mmHg after loading. Changes in the catecholamine index (CAI) (dopamine + dobutamine + (noradrenaline + adrenaline) × 100 μg/kg/min) from before loading to 2, 4, and 6 h after the initiation of vasopressin are shown. A Post 2 h—pre. B Post 4 h—pre. C Post—pre. Changes in CAI significantly differed between responders and non-responders at 2, 4, and 6 h

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References

    1. Patel BM, Chittock DR, Russell JA, Walley KR. Beneficial effects of short-term vasopressin infusion during severe septic shock. Anesthesiology. 2002;96(3):576–582. doi: 10.1097/00000542-200203000-00011. -DOI -PubMed
    1. Lauzier F, Lévy B, Lamarre P, Lesur O. Vasopressin or norepinephrine in early hyperdynamic septic shock: a randomized clinical trial. Intensive Care Med. 2006;32(11):1782–1789. doi: 10.1007/s00134-006-0378-0. -DOI -PubMed
    1. Russell JA, Walley KR, Singer J, et al. Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med. 2008;358(9):877–887. doi: 10.1056/NEJMoa067373. -DOI -PubMed
    1. Gordon AC, Mason AJ, Thirunavukkarasu N, et al. Effect of early vasopressin vs norepinephrine on kidney failure in patients with septic shock: The VANISH randomized clinical trial. JAMA. 2016;316(5):509–518. doi: 10.1001/jama.2016.10485. -DOI -PubMed
    1. Hayes MA, Yau EH, Hinds CJ, Watson JD. Symmetrical peripheral gangrene: association with noradrenaline administration. Intensive Care Med. 1992;18(7):433–436. doi: 10.1007/BF01694349. -DOI -PubMed

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