Interaction of vasopressin infusion, corticosteroid treatment, and mortality of septic shock

St Paul's Hospital, iCAPTURE Centre, Canada.
Critical care medicine (Impact Factor: 6.31). 04/2009; 37(3):811-8. DOI: 10.1097/CCM.0b013e3181961ace
Source: PubMed


Vasopressin and corticosteroids are often added to support cardiovascular dysfunction in patients who have septic shock that is nonresponsive to fluid resuscitation and norepinephrine infusion. However, it is unknown whether vasopressin treatment interacts with corticosteroid treatment.
Post hoc substudy of a multicenter randomized blinded controlled trial of vasopressin vs. norepinephrine in septic shock.
Twenty-seven Intensive Care Units in Canada, Australia, and the United States.
: Seven hundred and seventy-nine patients who had septic shock and were ongoing hypotension requiring at least 5 microg/min of norepinephrine infusion for 6 hours.
Patients were randomized to blinded vasopressin (0.01-0.03 units/min) or norepinephrine (5-15 microg/min) infusion added to open-label vasopressors. Corticosteroids were given according to clinical judgment at any time in the 28-day postrandomization period.
The primary end point was 28-day mortality. We tested for interaction between vasopressin treatment and corticosteroid treatment using logistic regression. Secondary end points were organ dysfunction, use of open-label vasopressors and vasopressin levels.
There was a statistically significant interaction between vasopressin infusion and corticosteroid treatment (p = 0.008). In patients who had septic shock and were also treated with corticosteroids, vasopressin, compared to norepinephrine, was associated with significantly decreased mortality (35.9% vs. 44.7%, respectively, p = 0.03). In contrast, in patients who did not receive corticosteroids, vasopressin was associated with increased mortality compared with norepinephrine (33.7% vs. 21.3%, respectively, p = 0.06). In patients who received vasopressin infusion, use of corticosteroids significantly increased plasma vasopressin levels by 33% at 6 hours (p = 0.006) to 67% at 24 hours (p = 0.025) compared with patients who did not receive corticosteroids.
There is a statistically significant interaction between vasopressin and corticosteroids. The combination of low-dose vasopressin and corticosteroids was associated with decreased mortality and organ dysfunction compared with norepinephrine and corticosteroids.

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    • "Interestingly, in patients who did not receive corticosteroids, AVP compared to NE group had increased mortality. Steroids use also increased plasma vasopressin levels by 33% [52]. Similar findings were described in retrospective studies in different populations [12] [13]. "
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    Critical care research and practice 09/2013; 2013:654708. DOI:10.1155/2013/654708
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    • "The sinus node of the heart integrates many inputs to determine the interval between successive heartbeats. Heart rate variability (HRV), a measure of both sympathovagal balance and the overall integrity/health of the baroreflex system, has been shown to offer unique insights into severity of illness in primary cardiac disease [5] [6] [7], acute trauma [8] and sepsis [9] [10]. Connections between the parasympathetic nervous system and inflammation suggest the possibility that HRV and inflammation may be interdependent [11]. "
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    Journal of critical care 08/2013; 28(6). DOI:10.1016/j.jcrc.2013.07.050 · 2.00 Impact Factor
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    • "Many of the patients in VASST were treated with corticosteroids because patients had septic shock. We therefore evaluated the interaction of vasopressin infusion, corticosteroid treatment, and mortality of septic shock in VASST [89]. Low-dose vasopressin infusion plus corticosteroids significantly decreased 28-day mortality compared with corticosteroid plus norepinephrine treatment (44.7 to 35.9%, P = 0.03; P = 0.008 interaction statistic). "
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