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

St Paul's Hospital, iCAPTURE Centre, Canada.
Critical care medicine (Impact Factor: 6.15). 04/2009; 37(3):811-8. DOI: 10.1097/CCM.0b013e3181961ace
Source: PubMed

ABSTRACT 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.

Download full-text


Available from: John Granton, Aug 16, 2015
  • Source
    • "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]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: There is no consensual definition of refractory shock. The use of more than 0.5 mcg/kg/min of norepinephrine or epinephrine to maintain target blood pressure is often used in clinical trials as a threshold. Nearly 6% of critically ill patients will develop refractory shock, which accounts for 18% of deaths in intensive care unit. Mortality rates are usually greater than 50%. The assessment of fluid responsiveness and cardiac function can help to guide therapy, and inotropes may be used if hypoperfusion signs persist after initial resuscitation. Arginine vasopressin is frequently used in refractory shock, although definite evidence to support this practice is still missing. Its associations with corticosteroids improved outcome in observational studies and are therefore promising alternatives. Other rescue therapies such as terlipressin, methylene blue, and high-volume isovolemic hemofiltration await more evidence before use in routine practice.
    Critical care research and practice 09/2013; 2013:654708. DOI:10.1155/2013/654708
  • Source
    • "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]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Heart rate variability (HRV) reflects autonomic nervous system tone as well as the overall health of the baroreflex system. We hypothesized that loss of complexity in HRV upon intensive care unit (ICU) admission would be associated with unsuccessful early resuscitation of sepsis. We prospectively enrolled patients admitted to ICUs with severe sepsis or septic shock from 2009 to 2011. We studied 30 minutes of electrocardiogram, sampled at 500 Hz, at ICU admission and calculated heart rate complexity via detrended fluctuation analysis. Primary outcome was vasopressor independence at 24 hours after ICU admission. Secondary outcome was 28-day mortality. We studied 48 patients, of whom 60% were vasopressor independent at 24 hours. Five (10%) died within 28 days. The ratio of fractal alpha parameters was associated with both vasopressor independence and 28-day mortality (P = .04) after controlling for mean heart rate. In the optimal model, Sequential Organ Failure Assessment score and the long-term fractal α parameter were associated with vasopressor independence. Loss of complexity in HRV is associated with worse outcome early in severe sepsis and septic shock. Further work should evaluate whether complexity of HRV could guide treatment in sepsis.
    Journal of critical care 08/2013; 28(6). DOI:10.1016/j.jcrc.2013.07.050 · 2.19 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Continual updating of estimates required by most recursive estimation schemes often involves redundant usage of information and may result in system instabilities in the presence of bounded output disturbances. This paper investigates an algorithm which has the capability of eliminating these difficulties. Based on a set theoretic assumption, the algorithm yields modified least-squares estimates with a forgetting factor. It updates the estimates selectively depending on whether the observed data contain sufficient information. The information evaluation required at each step involves very simple computations. In addition, the parameter estimates are shown to converge asymptotically to a region around the true parameter at an exponential rate.
    Decision and Control, 1985 24th IEEE Conference on; 01/1986
Show more

Similar Publications