In this episode, I’ll discuss starting vasopressin at the same time as norepinephrine for patients in septic shock.
Previous studies that have evaluated adding vasopressin to norepinephrine in septic shock have waited up to 12 hours before adding vasopressin.
Because a delay in reaching a MAP of 65 mmHg or greater is associated with increased negative patient outcomes, researchers performed an open-label trial looking at the early initiation of vasopressin in patients with septic shock.
The study was split into two groups. In the combination therapy group, vasopressin was initiated as soon as possible after norepinephrine was started. In the monotherapy group, norepinephrine was titrated and a second vasopressor was added if norepinephrine alone failed to achieve a MAP of 65 mmHg.
The combination group ended up having vasopressin initiated within 4 hours of norepinephrine, and the time to achieve and maintain goal MAP was 5.7 hours in this group vs 7.6 hours with norepinephrine alone.
The authors concluded:
Patients treated with early, concomitant vasopressin and norepinephrine achieved and maintained MAP of 65 mm Hg faster than those receiving initial norepinephrine monotherapy, suggesting that overcoming vasopressin deficiency sooner may reduce the time patients spend in the early phase of septic shock.
Mortality was not different between groups, however, the sample size was 41 patients per group, so it remains to be seen if starting vasopressin at the same time as norepinephrine results in any clinically meaningful outcomes.
The study was conducted before the publication of the latest SCCM guidelines and so the dose of vasopressin used was 0.04 units/min rather than the newly recommended 0.03 units/min.
Hopefully, future investigators will continue this line of research to better quantify the benefits of concomitant vasopressor therapy.
For a chart explaining vasopressor choice in sepsis, go to my free download area at pharmacyjoe.com/free It’s download #3 on the list.
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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