In this episode, I’ll discuss an article about starting norepinephrine before fluid resuscitation is complete in septic shock.
Article
Effects of very early start of norepinephrine in patients with septic shock: a propensity score-based analysis
Lead author: Gustavo A. Ospina-Tascón
Published in the journal Critical Care February 2020
Background
The practice of giving fluids before vasopressors to insure intravascular volume is present for the pressor to ’squeeze’ is largely an assumption. The authors of this study sought to determine whether the optimal start of vasopressor therapy might be earlier than currently thought – perhaps even before completing the initial fluid loading in septic shock.
Methods
A total of 337 patients with sepsis requiring vasopressor support for at least 6 hours were analyzed. Data was prospectively collected and entered into a database from a single-center mixed patient ICU. Patients were classified into very-early or delayed vasopressor start categories. A very early start was considered the initiation of norepinephrine within or before the next hour of the first resuscitative fluid load. After this analysis was done, a propensity match was performed to match 93 patients in the very early group with 93 patients in the delayed start group.
Results
Patients subjected to very early vasopressors received significantly less resuscitation fluids both at vasopressor starting and during the first 8 hours of resuscitation. This difference was about 1 liter of fluid at both points. There was not a significant increase in acute renal failure and/or renal replacement therapy requirements in the very early group.
The very early group also had a significantly lower net fluid balance at 8 and 24 hours after the start of vasopressor therapy compared to the delayed group. In this study, very early vasopressor initiation was also associated with a significant reduction in the risk of death with an impressive hazard ratio of just 0.31.
Conclusion
The authors concluded:
A very early start of vasopressor support seems to be safe, might limit the amount of fluids to resuscitate septic shock, and could lead to better clinical outcomes.
Discussion
While these results are impressive there are many unanswered questions that deserve more investigation. Was it the early vasopressor start that resulted in less mortality? Or was it the lower use of resuscitation fluids, or less fluid accumulation, or even shortening of the hypotension time? At the very least however this study seems to identify the practice of early vasopressor therapy as safe.
To get a copy of the 7 questions I use for guided topic discussions on vasopressors sign up for my free download area at pharmacyjoe.com/free. It’s download #17 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.
Leave a Reply