In this episode, I’ll discuss at what dose of norepinephrine is it best to add vasopressin for patients with septic shock.
While vasopressin is certainly the next vasopressor to use after norepinephrine is started in a patient with hypotension from septic shock, nobody has demonstrated the ideal level of norepinephrine dose threshold past which vasopressin should be added.
A group of researchers set out to do just that with a Cluster-randomized, cluster-crossover, pragmatic clinical strategy trial and published their results in JAMA.
Data from just under 4000 patients across 13 hospitals were analyzed. The researchers had each site use either a low or high dose initiation threshold hospital-wide for a month, then cross over to the opposite strategy.
The low dose threshold added vasopressin when the norepinephrine dose reached 0.1 mcg/kg/min and the high dose group when it reached 0.4 mcg/kg/min.
The primary outcome was 28-day mortality and the key secondary outcome was kidney replacement therapy–free days through day 28.
Mortality at 28 days occurred in 31.8% of patients treated with the hospital-level strategy recommending initiation of vasopressin at a lower-dose threshold of other vasopressors vs 33.0% treated with the higher-threshold strategy. This difference was not significant. Patients in both strategies for vasopressin initiation had a median of 29 kidney replacement therapy–free days – again, no difference.
The authors concluded:
In this large, pragmatic clinical trial comparing the effectiveness of 2 hospital-level strategies for second-line vasopressor management in septic shock, a strategy recommending initiation of vasopressin at a lower dose of other vasopressors did not reduce 28-day mortality compared with a strategy recommending vasopressin initiation at a higher dose of other vasopressors.
This study indicates clinicians can be somewhat relaxed about when exactly vasopressin is added to norepinephrine, as long as it eventually does get added around 0.4 mcg/kg/min.
The article in this episode is a selection from my Hospital Pharmacy Academy’s weekly literature digest. Have you ever felt like your physician colleagues are one step ahead of you with new literature developments? Every week, Academy members are provided a summary curated and explained by me of the top hospital pharmacy-related articles published that week from over 20 major journals and sources to save you time and keep you up to date with the literature. To get immediate access, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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