In this episode, I’ll discuss the discontinuation order of vasopressors.
The first two vasopressors generally used to treat septic shock are norepinephrine and vasopressin. The usual strategy is to add vasopressin to norepinephrine. But what happens when the patient recovers and vasopressors need to be weaned?
There is little data to identify the appropriate strategy for weaning this combination of vasopressors in patients who are recovering from septic shock. A prospective randomized trial looked at the incidence of hypotension according to the discontinuation order of vasopressors in the management of septic shock.
Before enrollment was complete, a significant difference in the incidence of hypotension was found and the study was stopped early. Over two-thirds of the patients in the norepinephrine-first group versus less than one-quarter in the vasopressin-first group developed hypotension after tapering the first vasopressor. This difference was statistically significant.
These findings persisted at nearly the same percentages when the second vasopressor was tapered. The hazard ratio for hypotension from first tapering norepinephrine was 2.2.
Trials that are stopped early have frequently overestimated treatment effects. However, until further data are available, tapering vasopressin first could possibly result in a lower incidence of hypotension in patients recovering from septic shock who are on concomitant norepinephrine and vasopressin.
To those APPE students whose hospital rotation has been disrupted by recent events: One way I’d like to help is by providing free access to 8 essential training videos on topics that I discuss with students on my rotation. Get free 14-day access by going to pharmacyjoe.com/virtual.
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