Effects of short-term simultaneous infusion of dobutamine and terlipressin in patients with septic shock: the DOBUPRESS study

Vasopressin and Terlipressin in the Treatment of Vasodilatory Septic Shock: A Systematic Review

Background:

Vasodilatory septic shock unresponsive to fluid resuscitation requires the addition of vasopressors. Catecholamines remain the first line vasopressor therapy, but treatment failure is a potential problem. Vasopressin and its analogue, terlipressin, have been used for this indication.

Objective:

This systematic review aims to evaluate the effects of vasopressin and terlipressin on mortality and morbidity outcomes in patients with vasodilatory shock. Secondary outcomes include the effects of vasopressin and terlipressin on haemodynamic stability and organ function.

Method:

A computerised search of MEDLINE from January 1966 till June 2010 and screening of references of relevant articles were conducted. Only prospective, randomised controlled trials comparing vasopressin or terlipressin versus standard vasopressors or placebo were included.

Results:

Seven studies using vasopressin, three using terlipressin and one using both were identified. Four vasopressin trials assessing mortality and morbidity outcomes showed a trend towards benefit for mortality in adults but possibly adverse outcomes in a small paediatric study. No data was available on the long-term mortality and morbidity outcomes of terlipressin. Vasopressin and terlipressin were similar to standard vasopressors in maintaining haemodynamic parameters, while allowing a beneficial catecholamine-sparing effect. These agents also had a neutral to positive effect on organ function.

Conclusion:

Vasopressin and terlipressin was comparable to conventional agents in the maintenance of haemodynamic stability and organ function in vasodilatory shock. Since morbidity and mortality data do not differentiate vasopressin and terlipressin from catecholamines, their role remains unclear. More large studies evaluating the long-term outcomes in this group of patients are required.

Bench-to-bedside review: Vasopressin in the management of septic shock

This review of vasopressin in septic shock differs from previous reviews by providing more information on the physiology and pathophysiology of vasopressin and vasopressin receptors, particularly because of recent interest in more specific AVPR1a agonists and new information from the Vasopressin and Septic Shock Trial (VASST), a randomized trial of vasopressin versus norepinephrine in septic shock. Relevant literature regarding vasopressin and other AVPR1a agonists was reviewed and synthesized. Vasopressin, a key stress hormone in response to hypotension, stimulates a family of receptors: AVPR1a, AVPR1b, AVPR2, oxytocin receptors and purinergic receptors. Rationales for use of vasopressin in septic shock are as follows: first, a deficiency of vasopressin in septic shock; second, low-dose vasopressin infusion improves blood pressure, decreases requirements for norepinephrine and improves renal function; and third, a recent randomized, controlled, concealed trial of vasopressin versus norepinephrine (VASST) suggests low-dose vasopressin may decrease mortality of less severe septic shock. Previous clinical studies of vasopressin in septic shock were small or not controlled. There was no difference in 28-day mortality between vasopressin-treated versus norepinephrine-treated patients (35% versus 39%, respectively) in VASST. There was potential benefit in the prospectively defined stratum of patients with less severe septic shock (5 to 14 μg/minute norepinephrine at randomization): vasopressin may have lowered mortality compared with norepinephrine (26% versus 36%, respectively, P = 0.04 within stratum). The result was robust: vasopressin also decreased mortality (compared with norepinephrine) if less severe septic shock was defined by the lowest quartile of arterial lactate or by use of one (versus more than one) vasopressor at baseline. Other investigators found greater hemodynamic effects of higher dose of vasopressin (0.06 units/minute) but also unique adverse effects (elevated liver enzymes and serum bilirubin). Use of higher dose vasopressin requires further evaluation of efficacy and safety. There are very few studies of interactions of therapies in critical care - or septic shock - and effects on mortality. Therefore, the interaction of vasopressin infusion, corticosteroid treatment and mortality of septic shock was evaluated in VASST. Low-dose vasopressin infusion plus corticosteroids significantly decreased 28-day mortality compared with corticosteroids plus norepinephrine (44% versus 35%, respectively, P = 0.03; P = 0.008 interaction statistic). Prospective randomized controlled trials would be necessary to confirm this interesting interaction. In conclusion, low-dose vasopressin may be effective in patients who have less severe septic shock already receiving norepinephrine (such as patients with modest norepinephrine infusion (5 to 15 μg/minute) or low serum lactate levels). The interaction of vasopressin infusion and corticosteroid treatment in septic shock requires further study.

Vasopressors for hypotensive shock

BACKGROUND

Initial goal directed resuscitation for shock usually includes the administration of intravenous fluids, followed by initiating vasopressors. Despite obvious immediate effects of vasopressors on haemodynamics their effect on patient relevant outcomes remains controversial. This review was originally published in 2004 and was updated in 2011.

OBJECTIVES

Our primary objective was to assess whether particular vasopressors reduce overall mortality, morbidity, and health-related quality of life.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 2), MEDLINE, EMBASE, PASCAL BioMed, CINAHL, BIOSIS, and PsycINFO (from inception to March 2010). The original search was performed in November 2003. We also asked experts in the field and searched meta-registries for ongoing trials.

SELECTION CRITERIA

Randomized controlled trials comparing various vasopressor regimens for hypotensive shock.

DATA COLLECTION AND ANALYSIS

Two authors abstracted data independently. Disagreement between the authors was discussed and resolved with a third author. We used a random-effects model for combining quantitative data.

MAIN RESULTS

We identified 23 randomized controlled trials involving 3212 patients, with 1629 mortality outcomes. Six different vasopressors, alone or in combination, were studied in 11 different comparisons.All 23 studies reported mortality outcomes; length of stay was reported in nine studies. Other morbidity outcomes were reported in a variable and heterogeneous way. No data were available on quality of life or anxiety and depression outcomes. We classified 10 studies as being at low risk of bias for the primary outcome mortality; only four studies fulfilled all trial quality items.In summary, there was no difference in mortality in any of the comparisons between different vasopressors or combinations. More arrhythmias were observed in patients treated with dopamine compared to norepinephrine. Norepinephrine versus dopamine, as the largest comparison in 1400 patients from six trials, yielded almost equivalence (RR 0.95, 95% confidence interval 0.87 to 1.03). Vasopressors used as add-on therapy in comparison to placebo were not effective either. These findings were consistent among the few large studies as well as in studies with different levels of within-study bias risk.

AUTHORS' CONCLUSIONS

There is some evidence of no difference in mortality between norepinephrine and dopamine. Dopamine appeared to increase the risk for arrhythmia. There is not sufficient evidence of any difference between any of the six vasopressors examined. Probably the choice of vasopressors in patients with shock does not influence the outcome, rather than any vasoactive effect per se. There is not sufficient evidence that any one of the investigated vasopressors is clearly superior over others.

Inotropes in cardiac patients: update 2011

PURPOSE OF REVIEW

ICU patients frequently develop low output syndromes due to cardiac dysfunction, myocardial injury, and inflammatory activation. Conventional inotropic agents seem to be useful in restoring hemodynamic parameters and improving peripheral organ perfusion, but can increase short-term and long-term mortality in these patients. Novel inotropes may be promising in the management of ICU patients, having no serious adverse effects. This review summarizes all the current knowledge about the use of conventional and new inotropic agents in various clinical entities of critically ill patients.

RECENT FINDINGS

In recent European Society of Cardiology guidelines, inotropic agents are administered in patients with low output syndrome due to impaired cardiac contractility, and signs and symptoms of congestion. The most recommended inotropes in this condition are levosimendan and dobutamine (both class of recommendation: IIa, level of evidence: B). Recent data indicate that levosimendan may be useful in postmyocardial infarction cardiac dysfunction and septic shock through increasing coronary flow and attenuating inflammatory activation, respectively. Furthermore, calcium sensitizing by levosimendan can be effectively used for weaning of mechanical ventilation in postcardiac surgery patients and has also cardioprotective effect as expressed by the absence of troponin release in this patient population. Finally, new agents, such as istaroxime and cardiac myosin activators may be safe and improve central hemodynamics in experimental models of heart failure and heart failure patients in phase II clinical trials; however, large-scale randomized clinical trials are required.

SUMMARY

In an acute cardiac care setting, short-term use of inotropic agents is crucial for the restoration of arterial blood pressure and peripheral tissue perfusion, as well as weaning of cardiosurgery. New promising agents should be tested in randomized clinical trials.

Effects of combined arginine vasopressin and levosimendan on organ function in ovine septic shock

OBJECTIVE

To compare the effects of a first-line therapy of combined arginine vasopressin, levosimendan, and norepinephrine with arginine vasopressin + norepinephrine or norepinephrine alone in ovine septic shock.

DESIGN

Prospective, randomized, controlled laboratory experiment.

SETTING

University animal research facility.

SUBJECTS

Twenty-one chronically instrumented sheep.

INTERVENTIONS

After the onset of fecal peritonitis-induced septic shock (mean arterial pressure <60 mm Hg), sheep were randomly assigned to receive first-line treatment with arginine vasopressin (0.5 mU·kg·min), combined arginine vasopressin (0.5 mU·kg·min) and levosimendan (0.2 μg·kg·min), or normal saline (each n = 7) for 24 hrs. In all groups, open-label norepinephrine was additionally titrated to maintain mean arterial pressure at 70 ± 5 mm Hg, if necessary.

MEASUREMENTS AND MAIN RESULTS

Arginine vasopressin + levosimendan + norepinephrine improved left ventricular contractility (higher stroke work indices at similar or lower preload) and pulmonary function (Pao2/Fio2 ratio) when compared with the other groups (p < .05 each). Both nonadrenergic treatment strategies reduced open-label norepinephrine doses. However, only arginine vasopressin + levosimendan + norepinephrine limited fluid requirements and positive fluid balance vs. both other groups (p < .05 each). In addition, arginine vasopressin + levosimendan + norepinephrine increased mixed venous oxygen saturation as compared with arginine vasopressin + norepinephrine. Histologic tissue analyses and pulmonary hemeoxygenase-1 activity revealed no differences among groups. Notably, arginine vasopressin + levosimendan + norepinephrine therapy reduced pulmonary 3-nitrotyrosine levels (p = .028 vs. control animals) as well as urinary protein/creatinine ratio (p < .05 each) and slightly prolonged survival when compared with both other groups (4 hrs vs. arginine vasopressin + norepinephrine: p = .013; 7 hrs vs. norepinephrine alone: p = .003).

CONCLUSIONS

First-line cardiovascular support with combined arginine vasopressin and levosimendan supplemented with norepinephrine improves myocardial, vascular, pulmonary, and renal function as compared with arginine vasopressin + norepinephrine in septic shock.

Sublingual microcirculatory changes during high-volume hemofiltration in hyperdynamic septic shock patients

INTRODUCTION

Previous studies have suggested that high volume hemofiltration (HVHF) may contribute to revert hypotension in severe hyperdynamic septic shock patients. However, arterial pressure stabilization occurs due to an increase in systemic vascular resistance, which could eventually compromise microcirculatory blood flow and perfusion. The goal of this study was to determine if HVHF deteriorates sublingual microcirculation in severe hyperdynamic septic shock patients.

METHODS

This was a prospective, non-randomized study at a 16-bed, medical-surgical intensive care unit of a university hospital. We included 12 severe hyperdynamic septic shock patients (norepinephrine requirements > 0.3 μg/kg/min and cardiac index > 3.0 L/min/m2) who underwent a 12-hour HVHF as a rescue therapy according to a predefined algorithm. Sublingual microcirculation (Microscan for NTSC, Microvision Medical), systemic hemodynamics and perfusion parameters were assessed at baseline, at 12 hours of HVHF, and 6 hours after stopping HVHF.

RESULTS

Microcirculatory flow index increased after 12 hours of HVHF and this increase persisted 6 hours after stopping HVHF. A similar trend was observed for the proportion of perfused microvessels. The increase in microcirculatory blood flow was inversely correlated with baseline levels. There was no significant change in microvascular density or heterogeneity during or after HVHF. Mean arterial pressure and systemic vascular resistance increased while lactate levels decreased after the 12-hour HVHF.

CONCLUSIONS

The use of HVHF as a rescue therapy in patients with severe hyperdynamic septic shock does not deteriorate sublingual microcirculatory blood flow despite the increase in systemic vascular resistance.

Effects of a single dose of terlipressin on transcutaneous oxygen pressures

OBJECTIVE

Terlipressin (TP) is a potent vasoconstrictor, which is widely used in the treatment of bleeding esophageal varices and the hepatorenal syndrome. Side effects to TP are often related to skin hypoxaemia. The aim of the study was to investigate the transcutaneous oxygen pressures (TcPO(2) mmHg) after administration of 2 mg of TP.

PATIENTS AND METHODS

Nineteen patients with cirrhosis and ascites were included. TcPO(2) mmHg were measured continuously measured at the chest, abdominal wall and at the lower extremity at baseline and after 2 mg TP in 15 patients and placebo in 4 patients.

RESULTS

The mean whole body TcPO(2) decreased after TP by 34% (p < 0.005). The decrease was even more pronounced in the lower extremity: above knee -33% (50 vs. 33 mmHg, p = 0.01) and below knee -52% (52 vs. 26 mmHg, p = 0.001). Levels below 30 mmHg, were found in 60% of the patients after TP compared to 0% in the placebo group, p = 0.005. There were no significant changes in TcPO(2) after placebo. The baseline leg TcPO(2) correlated inversely with the MELD score (r = -0.64 and p < 0.003) and the increase in MAP after TP correlated inversely with TcPO(2) at the thorax (r = -0.60, p = 0.009).

CONCLUSIONS

Sixty percent of patients with decompensated cirrhosis develop hypoxaemia in the lower limb after one dose of TP.

Investigational vasopressin receptor modulators in the pipeline

The vasopressin system is complex and interacts with the central nervous, cardiovascular, renal, and hematological systems. Vasopressin plays an important role in the control of blood osmolarity and vascular tone, but is also involved in many other physiological events, which are mediated mainly via three types of vasopressin receptor: V1R, V2R, and V3R. V1R primarily mediate the vascular, and V2R the aquaretic, effects of vasopressin. Vasopressin may also interact with other receptors, like adrenergic and angiotensin-II receptors, or with distinct biological pathways, including those of nitric oxide and the K(ATP) channel. There are numerous clinical situations where vasopressin receptor modulators (agonists or antagonists) could be used. Currently, vasopressin and terlipressin are most commonly used to stimulate V1R in vasodilatory shock and cardiac arrest, while desmopressin, a synthetic analogue of vasopressin, acts on V2R; but new molecules are becoming available in the treatment of inappropriate antidiuretic hormone (ADH) secretion.

Terlipressin: a promising vasoactive agent in hemodynamic support of septic shock

BACKGROUND

At present, terlipressin is predominantly used for the management of bleeding gastric and esophageal varices, as well as hepato-renal syndrome secondary to liver cirrhosis. Owing to its high and relatively selective affinity to vascular V1 receptors, terlipressin is also increasingly used as an adjunct vasopressor agent in the management of vasodilatory hyperdynamic septic shock.

OBJECTIVE

This review article aims to summarize the available knowledge related to hemodynamic support with terlipressin in septic shock.

METHODS

For literature search, PubMed and specific keywords from the MeSH Database were used.

RESULTS/CONCLUSIONS

Terlipressin represents an effective pressor agent in patients with catecholamine-unresponsive septic shock. However, caution should be exercised, as terlipressin may contribute dose-dependently to vasoconstriction and a reflectory decrease in cardiac output. Additional studies are needed to clarify: i) the optimal time of therapy institution; ii) the efficacy and the dosages of continuous infusion versus bolus administration; and iii) the safety and efficacy of this compound in comparison with other nonspecific vasopressinergic drugs, such as arginine vasopressin. Whether or not terlipressin may improve the outcome of septic shock patients compared with standard therapy with catecholamines remains to be determined.

Continuous terlipressin versus vasopressin infusion in septic shock (TERLIVAP): a randomized, controlled pilot study

Introduction

Recent clinical data suggest that early administration of vasopressin analogues may be advantageous compared to a last resort therapy. However, it is still unknown whether vasopressin and terlipressin are equally effective for hemodynamic support in septic shock. The aim of the present prospective, randomized, controlled pilot trial study was, therefore, to compare the impact of continuous infusions of either vasopressin or terlipressin, when given as first-line therapy in septic shock patients, on open-label norepinephrine requirements.

Methods

We enrolled septic shock patients (n = 45) with a mean arterial pressure below 65 mmHg despite adequate volume resuscitation. Patients were randomized to receive continuous infusions of either terlipressin (1.3 μg·kg^-1·h^-1), vasopressin (.03 U·min^-1) or norepinephrine (15 μg·min^-1; n = 15 per group). In all groups, open-label norepinephrine was added to achieve a mean arterial pressure between 65 and 75 mmHg, if necessary. Data from right heart and thermo-dye dilution catheterization, gastric tonometry, as well as laboratory variables of organ function were obtained at baseline, 12, 24, 36 and 48 hours after randomization. Differences within and between groups were analyzed using a two-way ANOVA for repeated measurements with group and time as factors. Time-independent variables were compared with one-way ANOVA.

Results

There were no differences among groups in terms of systemic and regional hemodynamics. Compared with infusion of .03 U of vasopressin or 15 μg·min^-1 of norepinephrine, 1.3 μg·kg^-1·h^-1 of terlipressin allowed a marked reduction in catecholamine requirements (0.8 ± 1.3 and 1.2 ± 1.4 vs. 0.2 ± 0.4 μg·kg^-1·min^-1 at 48 hours; each P < 0.05) and was associated with less rebound hypotension (P < 0.05). At the end of the 48-hour intervention period, bilirubin concentrations were higher in the vasopressin and norepinephrine groups as compared with the terlipressin group (2.3 ± 2.8 and 2.8 ± 2.5 vs. 0.9 ± 0.3 mg·dL^-1; each P < 0.05). A time-dependent decrease in platelet count was only observed in the terlipressin group (P < 0.001 48 hours vs. BL).

Conclusions

The present study provides evidence that continuous infusion of low-dose terlipressin – when given as first-line vasopressor agent in septic shock – is effective in reversing sepsis-induced arterial hypotension and in reducing norepinephrine requirements.

Trial registration

ClinicalTrial.gov NCT00481572.

Review article: inotrope and vasopressor use in the emergency department

Shock is a common presentation to the ED, with the incidence of septic shock increasing in Australasia over the last decade. The choice of inotropic agent is likely dependent on previous experience and local practices of the emergency and other critical care departments. The relatively short duration of stay in the ED before transfer leaves little room for evaluating the appropriateness of and response to the agent chosen. Delays in transfer to inpatient facilities means that patients receive advanced critical care within the ED for longer, requiring initiation and titration of vasoactive agents in the ED. This article discusses the general concepts of shock and the indicators for inotrope and vasopressor use, revises the various agents available and reviews the current evidence for their use.