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Albertson TE, Chenoweth JA, Lewis JC, Pugashetti JV, Sandrock CE, Morrissey BM. The pharmacotherapeutic options in patients with catecholamine-resistant vasodilatory shock. Expert Rev Clin Pharmacol 2022; 15:959-976. [PMID: 35920615 DOI: 10.1080/17512433.2022.2110067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Septic and vasoplegic shock are common types of vasodilatory shock (VS) with high mortality. After fluid resuscitation and the use of catecholamine-mediated vasopressors (CMV), vasopressin, angiotensin II, methylene blue (MB) and hydroxocobalamin can be added to maintain blood pressure. AREAS COVERED VS treatment utilizes a phased approach with secondary vasopressors added to vasopressor agents to maintain an acceptable mean arterial pressure (MAP). This review covers additional vasopressors and adjunctive therapies used when fluid and catecholamine-mediated vasopressors fail to maintain target MAP. EXPERT OPINION Evidence supporting additional vasopressor agents in catecholamine resistant VS is limited to case reports, series, and a few randomized control trials (RCTs) to guide recommendations. Vasopressin is the most common agent added next when MAPs are not adequately supported with CMV. VS patients failing fluids and vasopressors with cardiomyopathy may have cardiotonic agents such as dobutamine or milrinone added before or after vasopressin. Angiotensin II, another class of vasopressor is used in VS to maintain adequate MAP. MB and/or hydoxocobalamin, vitamin C, thiamine and corticosteroids are adjunctive therapies used in refractory VS. More RCTs are needed to confirm the utility of these drugs, at what doses, which combinations and in what order they should be given.
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Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA.,Department of Clinical Pharmacy, University of California, San Francisco, CA, USA
| | - James A Chenoweth
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
| | - Justin C Lewis
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Clinical Pharmacy, University of California, San Francisco, CA, USA
| | - Janelle V Pugashetti
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
| | - Christian E Sandrock
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
| | - Brian M Morrissey
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
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Schultz J, Andersen A, Lyhne MD, Arcanjo DDR, Kjaergaard B, Simonsen U, Nielsen-Kudsk JE. Terlipressin Increases Systemic and Lowers Pulmonary Arterial Pressure in Experimental Acute Pulmonary Embolism. Crit Care Med 2020; 48:e308-e315. [PMID: 32205621 DOI: 10.1097/ccm.0000000000004243] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES We investigated whether the vasopressin-analog, terlipressin induces systemic vasoconstriction and pulmonary vasodilation in a porcine model of acute pulmonary embolism. DESIGN Controlled, animal study. SETTING Tertiary medical center research laboratory. SUBJECTS Female pigs (n = 12, Cross of Land Race, Duroc, and Yorkshire ~ 60 kg). INTERVENTIONS Acute pulmonary embolism was induced by administration of three large autologous emboli. Animals then received four increasing doses of either terlipressin (n = 6) or vehicle (n = 6). MEASUREMENTS AND MAIN RESULTS Effects were evaluated in vivo at baseline, after pulmonary embolism and after each dose by invasive hemodynamic measures, transesophageal echocardiography, and blood analysis. Isolated pulmonary arteries were evaluated ex vivo in a myograph. Pulmonary embolism caused a four-fold increase in pulmonary vascular resistance (p < 0.0001) and a two-fold increase in mean pulmonary arterial pressure (p < 0.0001) compared with baseline. Terlipressin increased mean systemic blood pressure (28 ± 5 mm Hg; p < 0.0001) and systemic vascular resistance (1,320 ± 143 dynes; p < 0.0001) compared with vehicle. In the pulmonary circulation, terlipressin decreased mean pulmonary arterial pressure (-6.5 ± 1.8 mm Hg; p = 0.005) and tended to decrease pulmonary vascular resistance (-83 ± 33 dynes; p = 0.07). Terlipressin decreased cardiac output (-2.5 ± 0.5 L/min; p < 0.0001) and increased plasma lactate (2.7 ± 0.2 mmol/L; p < 0.0001), possibly indicating systemic hypoperfusion. A biomarker of cerebral ischemia, S100b, remained unchanged, suggesting preserved cerebral perfusion (0.17 ± 0.11 µg/L; p = 0.51). Ex vivo, terlipressin relaxed pulmonary and constricted mesenteric arteries. CONCLUSIONS Terlipressin caused systemic vasoconstriction and pulmonary vasodilation in a porcine in vivo model of acute pulmonary embolism and vasorelaxation in isolated pulmonary arteries. Despite positive vascular effects, cardiac output declined and plasma lactate increased probably due to a predominantly systemic vasoconstrictor effect of terlipressin. These findings should warrant careful translation to the clinical setting and does not suggest routine use in acute pulmonary embolism.
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Affiliation(s)
- Jacob Schultz
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Mads D Lyhne
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Daniel D R Arcanjo
- Department of Biophysics and Physiology, Federal University of Piauí, Teresina, Brazil
- Institute of Biomedicine, Aarhus University, Aarhus, Denmark
| | | | - Ulf Simonsen
- Institute of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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Huang P, Guo Y, Li B, Liu Q. Terlipressin Versus Norepinephrine for Septic Shock: A Systematic Review and Meta-Analysis. Front Pharmacol 2019; 10:1492. [PMID: 31920672 PMCID: PMC6936170 DOI: 10.3389/fphar.2019.01492] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 11/19/2019] [Indexed: 12/28/2022] Open
Abstract
Purpose: The meta-analysis aims to evaluate the efficacy and safety of terlipressin compared with norepinephrine for septic shock. Materials and Methods: The relevant studies from MEDLINE, Cochrane Library, Embase were searched by two independent investigators. A variety of keywords were used to search the studies. Stata software (version 11.0, Stata Corp LP, College Station, TX, USA) was used for statistical analysis. Results: A total of six studies were identified and incorporated into the meta-analysis. The results showed that there was no difference for 28-day mortality (RR = 0.99, 95% CI = [0.85,1.15], P = 0.849), AE (RR = 2.54, 95% CI = [0.58,11.08], P = 0.214), and MAP (SMD = -0.10, 95% CI = [-0.35,0.14], P = 0.405), OI, urinary output, Scr, total bilirubin, ALT, and AST between TP group and NE group. While TP could decrease HR at 24 and 48 h compared with NE. Conclusions: Current results suggest that terlipressin showed no added survival benefit for septic shock when compared with norepinephrine, while terlipressin could decrease heart rate in the late phase of septic shock compared with norepinephrine without further liver and kidney injury. Systematic Review Registration: PROSPERO (ID: CRD42019128743). Available online at: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42019128743.
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Affiliation(s)
- Po Huang
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Yuhong Guo
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Bo Li
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Infection and Immunity Laboratory, Beijing Institute of Traditional Chinese Medicine, Beijing, China
| | - Qingquan Liu
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Infection and Immunity Laboratory, Beijing Institute of Traditional Chinese Medicine, Beijing, China.,Infection and Immunity Laboratory, Beijing Key Laboratory of Basic Research With Traditional Chinese Medicine on Infectious Diseases, Beijing, China
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Jiang L, Sheng Y, Feng X, Wu J. The effects and safety of vasopressin receptor agonists in patients with septic shock: a meta-analysis and trial sequential analysis. Crit Care 2019; 23:91. [PMID: 30871607 PMCID: PMC6419432 DOI: 10.1186/s13054-019-2362-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 02/17/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate the effects and safety of vasopressin receptor agonists in patients with septic shock. METHODS PubMed, EMBASE, and Cochrane library were searched for randomized controlled trials evaluating the effects of vasopressin receptor agonists in septic shock patients. Two reviewers performed literature selection, data extraction, and quality evaluation independently. The primary outcome was mortality. And secondary outcomes included intensive care unit (ICU) length of stay, duration of mechanical ventilation, and incidence of adverse events. In addition, a trial sequential analysis (TSA) was performed. RESULTS Twenty studies were eligible for meta-analysis. The results showed vasopressin receptor agonists use was associated with reduced mortality (relative risk (RR) 0.92; 95% confidence interval (CI) 0.84 to 0.99; I2 = 0%). Nevertheless, they had no significant effects on ICU length of stay (mean deviation (MD) - 0.08, 95% CI, - 0.68 to 0.52, I2 = 0%) and duration of mechanical ventilation (MD - 0.58, 95% CI - 1.47 to 0.31, I2 = 57%). Additionally, there was no significant difference in total adverse events between two groups (RR 1.28, 95% CI 0.87 to 1.90, I2 = 57%), but vasopressin receptor agonists administration could significantly increase the risk of digital ischemia (RR 4.85, 95% CI 2.81 to 8.39, I2 = 26%). Finally, there was no statistical difference of cardiovascular events (RR 0.91, 95% CI 0.53 to 1.57, I2 = 1%), arrhythmia (0.77, 95% CI 0.48 to 1.23, I2 = 23%), mesenteric ischemia (0.83, 95% CI 0.44 to 1.55, I2 = 0%), diarrhea (2.47, 95% CI 0.77 to 7.96, I2 = 49%), cerebrovascular events (1.36, 95% CI 0.18 to 10.54, I2 = 0%), and hyponatremia (1.47, 95% CI 0.84 to 2.55, I2 = 0%) between two groups. Egger's test showed there was no significant publication bias among studies (P = 0.36). CONCLUSIONS The use of vasopressin might result in reduced mortality in patients with septic shock. An increased risk of digital ischemia must be taken into account.
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Affiliation(s)
- Libing Jiang
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, No 88, Jiefang Rd, Hangzhou, China
| | - Yi Sheng
- Yuhang Branch of The Second Affiliated Hospital of Zhenjiang University, No.369 Yingbin Road, Yuhang District, Hangzhou, 311100 Zhenjiang Province China
| | - Xia Feng
- Department of Respiratory, The Third People’s Hospital of Hangzhou, West Lake Avenue 38, Hangzhou, China
| | - Jing Wu
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, No 88, Jiefang Rd, Hangzhou, China
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Post EH, Su F, Righy Shinotsuka C, Taccone FS, Creteur J, De Backer D, Vincent JL. Renal autoregulation in experimental septic shock and its response to vasopressin and norepinephrine administration. J Appl Physiol (1985) 2018; 125:1661-1669. [PMID: 30260750 DOI: 10.1152/japplphysiol.00783.2017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Evidence suggests that septic shock patients with chronic arterial hypertension may benefit from resuscitation targeted to achieve higher blood pressure values than other patients, possibly as a result of altered renal autoregulation. The effects of different vasopressor agents on renal autoregulation may be important in this context. We investigated the effects of arginine vasopressin (AVP) and norepinephrine (NE) on renal autoregulation in ovine septic shock. Sepsis was induced by fecal peritonitis. When shock developed (decrease in mean arterial pressure to <65 mmHg and no fluid-responsiveness), animals were randomized to receive NE or AVP in a crossover design. Before the switch to the second vasopressor, the first vasopressor was discontinued for 30 minutes to ensure complete washout of the first vasopressor. Renal autoregulation was evaluated by recording the change in renal blood flow (RBF) in response to manual, stepwise reductions in renal inflow pressure. In this model, the lower limit of renal autoregulation was not significantly altered 6 hours after sepsis induction (59±9 vs. 64±7 mmHg at baseline, p=0.096). After development of shock, the autoregulatory threshold was lower with AVP than with NE (59±5 vs. 65±7 mmHg, p=0.010). However, RBF was higher with NE both at the start of autoregulatory measurements (206±58 vs. 170±52 mL/min; p=0.050) and at the autoregulatory threshold (191±53 vs. 150±47 mL/min; p=0.008). As vasopressors may have different effects on renal autoregulation, blood pressure management in patients with septic shock should be individualized and take into account drug-specific effects.
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Terlipressin versus norepinephrine as infusion in patients with septic shock: a multicentre, randomised, double-blinded trial. Intensive Care Med 2018; 44:1816-1825. [PMID: 29971593 DOI: 10.1007/s00134-018-5267-9] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 06/05/2018] [Indexed: 02/05/2023]
Abstract
PURPOSE Recent clinical data suggest that terlipressin, a vasopressin analogue, may be more beneficial in septic shock patients than catecholamines. However, terlipressin's effect on mortality is unknown. We set out to ascertain the efficacy and safety of continuous terlipressin infusion compared with norepinephrine (NE) in patients with septic shock. METHODS In this multicentre, randomised, double-blinded trial, patients with septic shock recruited from 21 intensive care units in 11 provinces of China were randomised (1:1) to receive either terlipressin (20-160 µg/h with maximum infusion rate of 4 mg/day) or NE (4-30 µg/min) before open-label vasopressors. The primary endpoint was mortality 28 days after the start of infusion. Primary efficacy endpoint analysis and safety analysis were performed on the data from a modified intention-to-treat population. RESULTS Between 1 January 2013 and 28 February 2016, 617 patients were randomised (312 to the terlipressin group, 305 to the NE group). The modified intention-to-treat population comprised 526 (85.3%) patients (260 in the terlipressin group and 266 in the NE group). There was no significant difference in 28-day mortality rate between the terlipressin group (40%) and the NE group (38%) (odds ratio 0.93 [95% CI 0.55-1.56]; p = 0.80). Change in SOFA score on day 7 was similar between the two groups: - 7 (IQR - 11 to 3) in the terlipressin group and - 6 (IQR - 10 to 5) in the NE group. There was no difference between the groups in the number of days alive and free of vasopressors. Overall, serious adverse events were more common in the terlipressin group than in the NE group (30% vs 12%; p < 0.001). CONCLUSIONS In this multicentre, randomised, double-blinded trial, we observed no difference in mortality between terlipressin and NE infusion in patients with septic shock. Patients in the terlipressin group had a higher number of serious adverse events. TRIAL REGISTRATION This trial is registered at ClinicalTrials.gov: ID NCT01697410.
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Kampmeier TG, Arnemann PH, Hessler M, Seidel LM, Becker K, Morelli A, Rehberg SW, Ertmer C. Comparison of first-line and second-line terlipressin versus sole norepinephrine in fulminant ovine septic shock. Sci Rep 2018; 8:7105. [PMID: 29740065 PMCID: PMC5940827 DOI: 10.1038/s41598-018-25570-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 04/23/2018] [Indexed: 12/31/2022] Open
Abstract
The Surviving Sepsis Guidelines suggest the use of vasopressin in case of catecholamine-refractory septic shock. Terlipressin (TP) as a V1-selective AVP analogue is a potential alternative, though data regarding the first-line administration in septic shock are scarce. The present study explored and compared the effects of first-line vs. second-line infusion of TP or sole norepinephrine regarding organ function, fluid and norepinephrine requirements and survival in fulminant ovine septic shock. Peritoneal sepsis was induced in 23 ewes after laparotomy and faecal withdrawal from the caecum. After onset of shock, causal and supportive sepsis therapy (antibiotics, peritoneal lavage, fluids and open-label norepinephrine) was performed in all animals. Concurrently, animals were randomized to receive 0.9% sodium chloride (control group) or TP (2 µg∙kg-1∙h-1, first-line group) after shock onset. In the second-line TP group, TP (2 µg∙kg-1∙h-1) was started once norepinephrine requirements exceeded 0.5 µg∙kg-1∙min-1. No significant differences were found between groups regarding survival, haemodynamics as well as fluid- and catecholamine-requirements. Kidney function and electron microscopic kidney injury were comparable between groups. In the present model of fulminant ovine septic shock, first-line TP infusion had no significant effect on fluid and norepinephrine requirements or organ dysfunction as compared to second-line TP infusion or placebo.
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Affiliation(s)
- Tim G Kampmeier
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany.
| | - Philip H Arnemann
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Michael Hessler
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Laura M Seidel
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Karsten Becker
- Institute of Medical Microbiology, University Hospital of Muenster, Muenster, Germany
| | - Andrea Morelli
- Department of Anaesthesiology and Intensive Care, University of Rome, "La Sapienza", Rome, Italy
| | - Sebastian W Rehberg
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital of Greifswald, Greifswald, Germany
| | - Christian Ertmer
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
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Tseng TL, Chen MF, Liu CH, Pang CY, Hsu YH, Lee TJF. Induction of endothelium-dependent constriction of mesenteric arteries in endotoxemic hypotensive shock. Br J Pharmacol 2016; 173:1179-95. [PMID: 26694894 DOI: 10.1111/bph.13415] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 12/06/2015] [Accepted: 12/15/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND PURPOSE Effective management of hypotension refractory to vasoconstrictors in severe sepsis is limited. A new strategy to ameliorate endotoxemic hypotension by inducing endothelium-dependent constriction of large arteries was assessed. EXPERIMENTAL APPROACH Endotoxemia in rats was induced by injection of LPS (10 mg·kg(-1), i.v.). Haemodynamics were measured in vivo, reactivity of isolated mesenteric arteries by myography and expression of proteins and enzyme activities by immunohistochemistry, biochemistry and molecular biology. KEY RESULTS Six hours after LPS, the hypotension was promptly reversed following injection (i.v. or i.p.) of oroxylin-A (OroA) . In isolated LPS-treated but not normal mesenteric arteries, OroA (1-10 μM) induced endothelium-dependent, sustained constriction, blocked by endothelin-1 (ET-1) receptor antagonists. OroA further enhanced LPS-induced expression of endothelin-converting enzyme, ET-1 mRNA and proteins and ET-1 release, OroA also enhanced phosphorylation of Rho-associated protein kinase (ROCK) and reversed LPS-induced suppression of RhoA activities in smooth muscle of arteries with endothelium. Activated- phosphorylation of smooth muscle ROCK was blocked by ET-1-receptor antagonists and ROCK inhibitors. Moreover, OroA post-treatment suppressed, via inhibiting NF-κB activation, inducible NOS expression and circulating NO. CONCLUSIONS AND IMPLICATIONS Reversal of endotoxemic hypotensive by OroA was due to release of endothelial ET-1, upregulated by LPS, from mesenteric arteries, inducing prompt and sustained vasoconstriction via activation of vascular smooth muscle RhoA/ROCK-pathway. In late endotoxemia, OroA-induced vasoconstriction was partly due to decreased circulating NO. Activation of endothelium-dependent constriction in large resistance arteries and suppression of systemic inflammation offer new strategies for acute management of endotoxemic hypotensive shock.
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Affiliation(s)
- Tzu-Ling Tseng
- Department of Medical Research, Buddhist Tzu Chi General Hospital, Hualien, Taiwan.,Institutes of Medical Sciences and Pharmacology & Toxicology, Hualien, Taiwan.,Department of Life Sciences, Tzu Chi Center of Vascular Medicine, College of Life Sciences, Hualien, Taiwan
| | - Mei-Fang Chen
- Department of Medical Research, Buddhist Tzu Chi General Hospital, Hualien, Taiwan.,Department of Life Sciences, Tzu Chi Center of Vascular Medicine, College of Life Sciences, Hualien, Taiwan.,Tzu Chi College of Technology, Hualien, Taiwan
| | - Chin-Hung Liu
- Department of Medical Research, Buddhist Tzu Chi General Hospital, Hualien, Taiwan.,Institutes of Medical Sciences and Pharmacology & Toxicology, Hualien, Taiwan.,Department of Life Sciences, Tzu Chi Center of Vascular Medicine, College of Life Sciences, Hualien, Taiwan
| | - Cheng-Yoong Pang
- Department of Medical Research, Buddhist Tzu Chi General Hospital, Hualien, Taiwan.,Institutes of Medical Sciences and Pharmacology & Toxicology, Hualien, Taiwan
| | - Yung-Hsiang Hsu
- Institutes of Medical Sciences and Pharmacology & Toxicology, Hualien, Taiwan.,Department of Pathology, College of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Tony J F Lee
- Department of Medical Research, Buddhist Tzu Chi General Hospital, Hualien, Taiwan.,Institutes of Medical Sciences and Pharmacology & Toxicology, Hualien, Taiwan.,Department of Life Sciences, Tzu Chi Center of Vascular Medicine, College of Life Sciences, Hualien, Taiwan.,Department of Pharmacology, Southern Illinois University School of Medicine, Springfield, IL, USA
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Belletti A, Musu M, Silvetti S, Saleh O, Pasin L, Monaco F, Hajjar LA, Fominskiy E, Finco G, Zangrillo A, Landoni G. Non-Adrenergic Vasopressors in Patients with or at Risk for Vasodilatory Shock. A Systematic Review and Meta-Analysis of Randomized Trials. PLoS One 2015; 10:e0142605. [PMID: 26558621 PMCID: PMC4641698 DOI: 10.1371/journal.pone.0142605] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 10/23/2015] [Indexed: 11/20/2022] Open
Abstract
Introduction Hypotensive state is frequently observed in several critical conditions. If an adequate mean arterial pressure is not promptly restored, insufficient tissue perfusion and organ dysfunction may develop. Fluids and catecholamines are the cornerstone of critical hypotensive states management. Catecholamines side effects such as increased myocardial oxygen consumption and development of arrhythmias are well known. Thus, in recent years, interest in catecholamine-sparing agents such as vasopressin, terlipressin and methylene blue has increased; however, few randomized trials, mostly with small sample sizes, have been performed. We therefore conducted a meta-analysis of randomized trials to investigate the effect of non-catecholaminergic vasopressors on mortality. Methods PubMed, BioMed Central and Embase were searched (update December 31st, 2014) by two independent investigators. Inclusion criteria were: random allocation to treatment, at least one group receiving a non-catecholaminergic vasopressor, patients with or at risk for vasodilatory shock. Exclusion criteria were: crossover studies, pediatric population, non-human studies, studies published as abstract only, lack of data on mortality. Studied drugs were vasopressin, terlipressin and methylene blue. Primary endpoint was mortality at the longest follow-up available. Results A total of 1,608 patients from 20 studies were included in our analysis. The studied settings were sepsis (10/20 studies [50%]), cardiac surgery (7/20 [35%]), vasodilatory shock due to any cause (2/20 [19%]), and acute traumatic injury (1/20 [5%]). Overall, pooled estimates showed that treatment with non-catecholaminergic agents improves survival (278/810 [34.3%] versus 309/798 [38.7%], risk ratio = 0.88, 95% confidence interval = 0.79 to 0.98, p = 0.02). None of the drugs was associated with significant reduction in mortality when analyzed independently. Results were not confirmed when analyzing studies with a low risk of bias. Conclusions Catecholamine-sparing agents in patients with or at risk for vasodilatory shock may improve survival. Further researches on this topic are needed to confirm the finding.
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Affiliation(s)
- Alessandro Belletti
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mario Musu
- Department of Medical Sciences “M. Aresu”, Cagliari University, Cagliari, Italy
| | - Simona Silvetti
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Omar Saleh
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Pasin
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabrizio Monaco
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ludhmila A. Hajjar
- Surgical Intensive Care Unit, Department of Cardiopneumology, University of São Paulo, São Paulo, Brazil
| | - Evgeny Fominskiy
- Department of Anaesthesiology and Intensive Care, Academician EN Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Gabriele Finco
- Department of Medical Sciences “M. Aresu”, Cagliari University, Cagliari, Italy
| | - Alberto Zangrillo
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- * E-mail:
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Devlin JJ, DeVito SS, Littlejohn LF, Gutierrez MA, Nowak G, Henao J, Bielawski A, Kotora J, Johnson AS. Terlipressin with limited fluid resuscitation in a swine model of hemorrhage. J Emerg Med 2013; 45:78-85. [PMID: 23602144 DOI: 10.1016/j.jemermed.2012.12.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2012] [Revised: 11/26/2012] [Accepted: 12/19/2012] [Indexed: 10/26/2022]
Abstract
BACKGROUND Principles of damage control resuscitation include minimizing intravenous fluid (IVF) administration while correcting perfusion pressure as quickly as possible. Recent studies have identified a potential advantage of vasopressin over catecholamines in traumatic shock. Terlipressin (TP) is a vasopressin analogue used to reverse certain shock etiologies in some European countries. STUDY OBJECTIVE We evaluated three dosages of TP when combined with a limited colloid resuscitation strategy on mean arterial pressure (MAP) and lactatemia in a swine model of isolated hemorrhage. METHODS Sixty anesthetized swine underwent intubation and severe hemorrhage. Subjects were randomized to one of four resuscitation groups: 4 mL/kg Hextend(®) (Hospira Inc, Lake Forest, IL) only, 3.75 μg/kg TP + Hextend, 7.5 μg/kg TP + Hextend, or 15 μg/kg TP + Hextend. MAP and heart rate were recorded every 5 min. Baseline and serial lactate values at 30-min intervals were recorded and compared. RESULTS Subjects receiving 7.5 μg/kg TP had significantly higher MAPs at times t15 (p = 0.012), t20 (p = 0.004), t25 (p = 0.018), t30 (p = 0.032), t35 (p = 0.030), and t40 (p = 0.021). No statistically significant differences in lactate values between TP groups and controls were observed. CONCLUSION Subjects receiving 7.5 μg/kg of TP demonstrated improved MAP within 10 min of administration. When combined with minimal IVF resuscitation, TP doses between 3.75 and 15 μg/kg do not elevate lactate levels in hemorrhaged swine.
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Affiliation(s)
- John J Devlin
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
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Romero-Bermejo FJ, Ruiz-Bailen M, Gil-Cebrian J, Huertos-Ranchal MJ. Sepsis-induced cardiomyopathy. Curr Cardiol Rev 2013; 7:163-83. [PMID: 22758615 PMCID: PMC3263481 DOI: 10.2174/157340311798220494] [Citation(s) in RCA: 188] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Revised: 02/24/2011] [Accepted: 02/24/2011] [Indexed: 01/20/2023] Open
Abstract
Myocardial dysfunction is one of the main predictors of poor outcome in septic patients, with mortality rates next to 70%. During the sepsis-induced myocardial dysfunction, both ventricles can dilate and diminish its ejection fraction, having less response to fluid resuscitation and catecholamines, but typically is assumed to be reversible within 7-10 days. In the last 30 years, It´s being subject of substantial research; however no explanation of its etiopathogenesis or effective treatment have been proved yet. The aim of this manuscript is to review on the most relevant aspects of the sepsis-induced myocardial dysfunction, discuss its clinical presentation, pathophysiology, etiopathogenesis, diagnostic tools and therapeutic strategies proposed in recent years.
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Affiliation(s)
- Francisco J Romero-Bermejo
- Intensive Care Unit, Critical Care and Emergency Department, Puerto Real University Hospital, Cadiz, Spain.
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Effects of terlipressin on pulmonary artery pressure in a septic cooled infant: an echocardiographic assessment. J Perinatol 2012; 32:893-5. [PMID: 23128058 DOI: 10.1038/jp.2011.181] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Experience with terlipressin (TP) in the neonatal field is scarce. We describe the effects of TP on pulmonary circulation, studied with echocardiography, in an asphyxiated septic cooled infant with pulmonary hypertension (PH) who developed catecholamine-resistant hypotension and exacerbation of PH shortly after the beginning of the rewarming. TP was added to norephinephine and adrenaline infusions at the dose of 0.02 mg kg(-1) every 6 h, because of refractory hypotension and oliguria. After 10 min, blood pressure dramatically and definitely increased, and urinary output was re-established after 60 min. Echocardiographic evaluation 30 min after the second bolus of TP showed unchanged velocity of the tricuspidal valve regurgitation and improved biventricular functional indexes respect to the pre-treatment assessment. TP was continued for 12 h (three doses) without significant adverse effect except for a transient increase in troponin levels. Addition of TP boluses to catecholamine infusion in our newborn was effective in increasing systemic vascular resistance without increasing pulmonary vascular resistance, successfully reversing the hemodynamics of severe PH, and suggesting a potential primary vasodilator effect on pulmonary circulation. Transient increase of troponin levels during TP treatment confirms the risk of excessive coronary vasoconstriction when TP boluses are added to high dose catecholamines.
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Oroxylin a, but not vasopressin, ameliorates cardiac dysfunction of endotoxemic rats. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2012. [PMID: 23193421 PMCID: PMC3489109 DOI: 10.1155/2012/408187] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The mortality in septic patients with myocardial dysfunction is higher than those without it. Beneficial effects of flavonoid oroxylin A (Oro-A) on endotoxemic hearts were evaluated and compared with that of arginine vasopressin (AVP) which is used to reverse hypotension in septic patients. Endotoxemia in rats was induced by one-injection of lipopolysaccharides (LPS, 10 mg/kg, i.p.), and hearts were isolated 5-hrs or 16-hrs later. Isolated hearts with constant-pressure or constant-flow mode were examined by Langendorff technique. Rate and force of contractions of isolated atrial and ventricular strips were examined by tissue myography. Isolated endotoxemic hearts were characterized by decreased or increased coronary flow (CF) in LPS-treated-for-5hr and LPS-treated-for-16-hr groups, respectively, with decreased inotropy in both groups. Oro-A-perfusion ameliorated while AVP-perfusion worsened the decreased CF and inotropy in both preparations. Oro-A and AVP, however, did not affect diminished force or rate of contraction of atrial and ventricular strips of endotoxemic hearts. Oro-A-induced CF increase was not affected following coronary endothelium-denudation with saponin. These results suggest that Oro-A ameliorates LPS-depressed cardiac functions by increasing CF, leading to positive inotropy. In contrast, AVP aggravates cardiac dysfunction by decreasing CF. Oro-A is a potentially useful candidate for treating endotoxemia complicated with myocardial dysfunction.
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Ishikawa K, Wan L, Calzavacca P, Bellomo R, Bailey M, May CN. The effects of terlipressin on regional hemodynamics and kidney function in experimental hyperdynamic sepsis. PLoS One 2012; 7:e29693. [PMID: 22355305 PMCID: PMC3280248 DOI: 10.1371/journal.pone.0029693] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 12/02/2011] [Indexed: 01/29/2023] Open
Abstract
Background and Aims Although terlipressin (TP) may improve renal function in cirrhotic patients, its use in sepsis remains controversial due to concerns about regional ischemia. We investigated the effects of TP on regional hemodynamics and kidney function in experimental hyperdynamic sepsis. Methods We studied thirteen merino ewes in a university physiology laboratory using a randomized controlled cross over design. We implanted flow probes around the pulmonary, circumflex coronary, superior mesenteric, renal and iliac arteries. We injected live Escherichia coli and induced hyperdynamic sepsis. We treated animals with either bolus vehicle or a single dose of TP (sTP = 1 mg). In a second group, after 1 mg of TP, two additional bolus injections (mTP) of 0.5 mg were given at 2 hourly intervals. Main Results sTP (1 mg) significantly increased mean arterial pressure (MAP) (74 to 89 mmHg; P<0.0001) creatinine clearance (31 to 85 mL/min; P<0.0001) and urine output (24 to 307 mL/hr) (P<0.0001). However, it decreased CO (5.7 to 3.9 L/min; p<0.0001), coronary blood flow (CBF) (43 to 32 mL/min; p<0.0001) and mesenteric blood flow (MBF) (944 to 625 mL/min; p = 0.004) and increased blood lactate (2.1 to 4.0 mmol/L; p<0.0001). Extra doses of TP caused little additional effect. Conclusions In hyperdynamic sepsis, bolus TP transiently improves MAP and renal function, but reduces CO, CBF and MBF, and increases blood lactate. Caution should be applied when prescribing bolus TP in septic patients at risk of coronary or mesenteric ischemia.
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Affiliation(s)
- Ken Ishikawa
- Howard Florey Institute, University of Melbourne, Parkville, Victoria, Australia
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Morelli A, Donati A, Ertmer C, Rehberg S, Kampmeier T, Orecchioni A, Di Russo A, D'Egidio A, Landoni G, Lombrano MR, Botticelli L, Valentini A, Zangrillo A, Pietropaoli P, Westphal M. Effects of vasopressinergic receptor agonists on sublingual microcirculation in norepinephrine-dependent septic shock. Crit Care 2011; 15:R217. [PMID: 21929764 PMCID: PMC3334762 DOI: 10.1186/cc10453] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Revised: 07/28/2011] [Accepted: 09/19/2011] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION The present study was designed to determine the effects of continuously infused norepinephrine (NE) plus (1) terlipressin (TP) or (2) arginine vasopressin (AVP) or (3) placebo on sublingual microcirculation in septic shock patients. The primary study end point was a difference of ≥ 20% in the microvascular flow index of small vessels among groups. METHODS The design of the study was a prospective, randomized, double-blind clinical trial. NE was titrated to maintain mean arterial pressure (MAP) between 65 and 75 mmHg after establishment of normovolemia in 60 septic shock patients. Thereafter patients (n = 20 per group) were randomized to receive continuous infusions of either TP (1 μg/kg/hour), AVP (0.04 U/minute) or placebo (isotonic saline). In all groups, open-label NE was adjusted to maintain MAP within threshold values if needed. The sublingual microcirculatory blood flow of small vessels was assessed by sidestream dark-field imaging. All measurements, including data from right heart catheterization and norepinephrine requirements, were obtained at baseline and 6 hours after randomization. RESULTS TP and AVP decreased NE requirements at the end of the 6-hour study period. The data are medians (25th and 75th interquartile ranges (IQRs)): 0.57 μg/kg/minute (0.29 to 1.04) vs. 0.16 μg/kg/minute (0.03 to 0.37) for TP and 0.40 μg/kg/minute (0.20 to 1.05) vs. 0.23 μg/kg/minute (0.03 to 0.77) for AVP, with statistical significance of P < 0.05 vs. baseline and vs. placebo. There were no differences in sublingual microcirculatory variables, systemic hemodynamics, oxygen transport and acid-base homeostasis among the three study groups during the entire observation period. The proportions of perfused vessels increased in relation to baseline within all study groups, and there were no significant differences between groups. The specific data were as follows (median (IQR)): 9.7% (2.6 to 19.8) for TP, 8.9% (0.0 to 17.8) for AVP, and 6.9% (3.5 to 10.1) for placebo (P < 0.05 vs. baseline for each comparison), as well as perfused vessel density 18.6% (8.6 to 36.9) for TP, 20.2% (-3.0 to 37.2) for AVP, and 11.4% (-3.0 to 19.4) for placebo (P < 0.05 vs. baseline for each comparison). CONCLUSIONS The present study suggests that to achieve a MAP of 65 to 75 mmHg in septic patients treated with NE, the addition of continuously infused low-dose TP or AVP does not affect sublingual microcirculatory blood flow. In addition, our results suggest that microcirculatory flow abnormalities are mainly related to other factors (for example, volume status, timing, hemodynamics and progression of the disease) rather than to the vasopressor per se. TRIAL REGISTRATION ClinicalTrial.gov NCT00995839.
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Affiliation(s)
- Andrea Morelli
- Department of Anesthesiology and Intensive Care, University of Rome, "La Sapienza," Viale del Policlinico 155, Rome I-00161, Italy
| | - Abele Donati
- Department of Neuroscience-Anesthesia and Intensive Care Unit, Università Politecnica delle Marche, Via Tronto 10, Torrette di Ancona I-60020, Italy
| | - Christian Ertmer
- Department of Anesthesiology and Intensive Care, University Hospital of Muenster, Albert-Schweitzer-Strasse 33, Muenster D-48149, Germany
| | - Sebastian Rehberg
- Department of Anesthesiology and Intensive Care, University Hospital of Muenster, Albert-Schweitzer-Strasse 33, Muenster D-48149, Germany
| | - Tim Kampmeier
- Department of Anesthesiology and Intensive Care, University Hospital of Muenster, Albert-Schweitzer-Strasse 33, Muenster D-48149, Germany
| | - Alessandra Orecchioni
- Department of Anesthesiology and Intensive Care, University of Rome, "La Sapienza," Viale del Policlinico 155, Rome I-00161, Italy
| | - Alessandro Di Russo
- Department of Anesthesiology and Intensive Care, University of Rome, "La Sapienza," Viale del Policlinico 155, Rome I-00161, Italy
| | - Annalia D'Egidio
- Department of Anesthesiology and Intensive Care, University of Rome, "La Sapienza," Viale del Policlinico 155, Rome I-00161, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, Università Vita-Salute San Raffaele, Via Olgettina 60, Milan I-20132, Italy
| | - Maria Rita Lombrano
- Department of Neuroscience-Anesthesia and Intensive Care Unit, Università Politecnica delle Marche, Via Tronto 10, Torrette di Ancona I-60020, Italy
| | - Laura Botticelli
- Department of Neuroscience-Anesthesia and Intensive Care Unit, Università Politecnica delle Marche, Via Tronto 10, Torrette di Ancona I-60020, Italy
| | - Agnese Valentini
- Department of Neuroscience-Anesthesia and Intensive Care Unit, Università Politecnica delle Marche, Via Tronto 10, Torrette di Ancona I-60020, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, Università Vita-Salute San Raffaele, Via Olgettina 60, Milan I-20132, Italy
| | - Paolo Pietropaoli
- Department of Anesthesiology and Intensive Care, University of Rome, "La Sapienza," Viale del Policlinico 155, Rome I-00161, Italy
| | - Martin Westphal
- Department of Anesthesiology and Intensive Care, University Hospital of Muenster, Albert-Schweitzer-Strasse 33, Muenster D-48149, Germany
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Russell JA. Bench-to-bedside review: Vasopressin in the management of septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:226. [PMID: 21892977 PMCID: PMC3387647 DOI: 10.1186/cc8224] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- James A Russell
- Critical Care Medicine, St Paul's Hospital, 1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6.
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Saia RS, Oliveira-Pelegrin GR, da Silva MENB, Aguila FA, Antunes-Rodrigues J, Rocha MJA, Cárnio EC. Neonatal endotoxin exposure changes neuroendocrine, cardiovascular function and mortality during polymicrobial sepsis in adult rats. ACTA ACUST UNITED AC 2011; 169:21-30. [DOI: 10.1016/j.regpep.2011.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 03/01/2011] [Accepted: 04/16/2011] [Indexed: 01/09/2023]
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Short-term effects of terlipressin bolus infusion on sublingual microcirculatory blood flow during septic shock. Intensive Care Med 2011; 37:963-9. [DOI: 10.1007/s00134-011-2148-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 01/28/2011] [Indexed: 01/09/2023]
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Osmoregulation of vasopressin secretion is altered in the postacute phase of septic shock. Crit Care Med 2010; 38:1962-9. [PMID: 20639747 DOI: 10.1097/ccm.0b013e3181eb9acf] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine whether septic shock patients have an abnormal reponse to increasing osmolarity. DESIGN Prospective interventional study. SETTING Intensive care unit at Raymond Poincaré and Etampes Hospitals. PATIENTS Normonatremic patients at > 72 hrs from septic shock onset. INTERVENTION Osmotic challenge consisting of infusing 500 mL of hypertonic saline solution (with cumulative amount of sodium not exceeding 24 g) over 120 mins. MEASUREMENTS AND MAIN RESULTS Plasma arginine vasopressin levels were measured 15 mins before the test and then four times every 30 mins. A slope of the relation between arginine vasopressin and plasma sodium levels of < 0.5 pg/mEq defined nonresponders. Among the 33 included patients, 17 (52%) were nonresponders. During osmotic challenge, variations throughout the test in plasma sodium levels, blood pressure, and central venous pressure were comparable between the two groups. Arginine vasopressin increased from 4.8 pg/mL [3.3-6.4 pg/mL] to 14.4 pg/mL [11.2-23.3 pg/mL] in responders but only from 2.8 pg/mL [2.3-4.0 pg/mL] to 4.0 pg/mL [3.1-5.3 pg/mL] in nonresponders (p < .0001). Responders had a higher plasma arginine vasopressin levels at baseline and a more severe hematosis alteration. Nonresponders had more frequently bacteremia and liver dysfunction, been referred from the ward and undergone surgery. Critical illness severity, hemodynamic alteration, hydroelectrolytic disturbances, treatment, and outcome did not differ between the two groups. CONCLUSION Osmoregulation is dramatically altered in half of patients with prolonged septic shock.
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Bauer SR, Lam SW. Arginine Vasopressin for the Treatment of Septic Shock in Adults. Pharmacotherapy 2010; 30:1057-71. [DOI: 10.1592/phco.30.10.1057] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Levy B, Collin S, Sennoun N, Ducrocq N, Kimmoun A, Asfar P, Perez P, Meziani F. Vascular hyporesponsiveness to vasopressors in septic shock: from bench to bedside. Intensive Care Med 2010; 36:2019-29. [PMID: 20862451 DOI: 10.1007/s00134-010-2045-8] [Citation(s) in RCA: 150] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Accepted: 08/24/2010] [Indexed: 01/20/2023]
Abstract
PURPOSE To delineate some of the characteristics of septic vascular hypotension, to assess the most commonly cited and reported underlying mechanisms of vascular hyporesponsiveness to vasoconstrictors in sepsis, and to briefly outline current therapeutic strategies and possible future approaches. METHODS Source data were obtained from a PubMed search of the medical literature with the following MeSH terms: Muscle, smooth, vascular/physiopathology; hypotension/etiology; shock/physiopathology; vasodilation/physiology; shock/therapy; vasoconstrictor agents. RESULTS Nitric oxide (NO) and peroxynitrite are crucial components implicated in vasoplegia and vascular hyporeactivity. Vascular ATP-sensitive and calcium-activated potassium channels are activated during shock and participate in hypotension. In addition, shock state is characterized by inappropriately low plasma glucocorticoid and vasopressin concentrations, a dysfunction and desensitization of alpha-receptors, and an inactivation of catecholamines by oxidation. Numerous other mechanisms have been individualized in animal models, the great majority of which involve NO: MEK1/2-ERK1/2 pathway, H(2)S, hyperglycemia, and cytoskeleton dysregulation associated with decreased actin expression. CONCLUSIONS Many therapeutic approaches have proven their efficiency in animal models, especially therapies directed against one particular compound, but have otherwise failed when used in human shock. Nevertheless, high doses of catecholamines, vasopressin and terlipressin, hydrocortisone, activated protein C, and non-specific shock treatment have demonstrated a partial efficiency in reversing sepsis-induced hypotension.
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Affiliation(s)
- B Levy
- Groupe Choc, Contrat Avenir INSERM 2006, Faculté de Médecine, Nancy Université, 9 Avenue de la Forêt de Haye, BP 184, Vandœuvre-lès-Nancy Cedex, 54505, France.
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Elzouki AN, El-Menyar A, Ahmed E, Elbadri ME, Imam YZ, Gurbanna BA. Terlipressin-induced severe left and right ventricular dysfunction in patient presented with upper gastrointestinal bleeding: case report and literature review. Am J Emerg Med 2010; 28:540.e1-6. [DOI: 10.1016/j.ajem.2009.08.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 08/03/2009] [Indexed: 11/30/2022] Open
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Holt NF, Haspel KL. Vasopressin: A Review of Therapeutic Applications. J Cardiothorac Vasc Anesth 2010; 24:330-47. [DOI: 10.1053/j.jvca.2009.09.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2009] [Indexed: 01/03/2023]
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Favory R, Salgado DR, Vincent JL. Investigational vasopressin receptor modulators in the pipeline. Expert Opin Investig Drugs 2010; 18:1119-31. [PMID: 19589090 DOI: 10.1517/13543780903066764] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Raphaël Favory
- Université Libre de Bruxelles, Erasme Hospital, Department of Intensive Care, Brussels, Belgium
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Morelli A, Ertmer C, Pietropaoli P, Westphal M. Terlipressin: a promising vasoactive agent in hemodynamic support of septic shock. Expert Opin Pharmacother 2009; 10:2569-75. [PMID: 19735216 DOI: 10.1517/14656560903257808] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- Andrea Morelli
- Department of Anesthesiology and Intensive Care, University of Rome - La Sapienza, Rome 00161, Italy.
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Torgersen C, Dünser MW, Wenzel V, Jochberger S, Mayr V, Schmittinger CA, Lorenz I, Schmid S, Westphal M, Grander W, Luckner G. Comparing two different arginine vasopressin doses in advanced vasodilatory shock: a randomized, controlled, open-label trial. Intensive Care Med 2009; 36:57-65. [PMID: 19756505 DOI: 10.1007/s00134-009-1630-1] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2009] [Revised: 08/19/2009] [Accepted: 08/19/2009] [Indexed: 01/30/2023]
Abstract
PURPOSE To compare the effects of two arginine vasopressin (AVP) dose regimens on the hemodynamic response, catecholamine requirements, AVP plasma concentrations, organ function and adverse events in advanced vasodilatory shock. METHODS In this prospective, controlled, open-label trial, patients with vasodilatory shock due to sepsis, systemic inflammatory response syndrome or after cardiac surgery requiring norepinephrine >0.6 microg/kg/min were randomized to receive a supplementary AVP infusion either at 0.033 IU/min (n = 25) or 0.067 IU/min (n = 25). The hemodynamic response, catecholamine doses, laboratory and organ function variables as well as adverse events (decrease in cardiac index or platelet count, increase in liver enzymes or bilirubin) were recorded before, 1, 12, 24 and 48 h after randomization. A linear mixed effects model was used for statistical analysis in order to account for drop-outs during the observation period. RESULTS Heart rate and norepinephrine requirements decreased while MAP increased in both groups. Patients receiving AVP at 0.067 IU/min required less norepinephrine (P = 0.006) than those infused with AVP at 0.033 IU/min. Arterial lactate and base deficit decreased while arterial pH increased in both groups. During the observation period, AVP plasma levels increased in both groups (both P < 0.001), but were higher in the 0.067 IU/min group (P < 0.001) and in patients on concomitant hydrocortisone. The rate of adverse events and intensive care unit mortality was comparable between groups (0.033 IU/min, 52%; 0.067 IU/min, 52%; P = 1). CONCLUSIONS A supplementary AVP infusion of 0.067 IU/min restores cardiovascular function in patients with advanced vasodilatory shock more effectively than AVP at 0.033 IU/min.
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Affiliation(s)
- Christian Torgersen
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
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Indrambarya T, Boyd JH, Wang Y, McConechy M, Walley KR. Low-dose vasopressin infusion results in increased mortality and cardiac dysfunction following ischemia-reperfusion injury in mice. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R98. [PMID: 19549333 PMCID: PMC2717470 DOI: 10.1186/cc7930] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2009] [Revised: 06/02/2009] [Accepted: 06/23/2009] [Indexed: 11/24/2022]
Abstract
Introduction Arginine vasopressin is a vasoactive drug commonly used in distributive shock states including mixed shock with a cardiac component. However, the direct effect of arginine vasopressin on the function of the ischemia/reperfusion injured heart has not been clearly elucidated. Methods We measured left ventricular ejection fraction using trans-thoracic echocardiography in C57B6 mice, both in normal controls and following ischemia/reperfusion injury induced by a one hour ligation of the left anterior descending coronary artery. Mice were treated with one of normal saline, dobutamine (8.33 μg/kg/min), or arginine vasopressin (0.00057 Units/kg/min, equivalent to 0.04 Units/min in a 70 kg human) delivered by an intraperitoneal micro-osmotic pump. Arterial blood pressure was measured using a micromanometer catheter. In addition, mortality was recorded and cardiac tissues processed for RNA and protein. Results Baseline left ventricular ejection fraction was 65.6% (60 to 72). In normal control mice, there was no difference in left ventricular ejection fraction according to infusion group. Following ischemia/reperfusion injury, AVP treatment significantly reduced day 1 left ventricular ejection fraction 46.2% (34.4 to 52.0), both in comparison with baseline and day 1 saline treated controls 56.9% (42.4 to 60.2). There were no significant differences in preload (left ventricular end diastolic volume), afterload (blood pressure) or heart rate to account for the effect of AVP on left ventricular ejection fraction. The seven-day mortality rate was highest in the arginine vasopressin group. Following ischemia/reperfusion injury, we found no change in cardiac V1 Receptor expression but a 40% decrease in Oxytocin Receptor expression. Conclusions Arginine vasopressin infusion significantly depressed the myocardial function in an ischemia/reperfusion model and increased mortality in comparison with both saline and dobutamine treated animals. The use of vasopressin may be contraindicated in non-vasodilatory shock states associated with significant cardiac injury.
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Affiliation(s)
- Toonchai Indrambarya
- Critical Care Research Laboratories, Heart + Lung Institute, University of British Columbia, Vancouver, British Columbia V6Z 1Y6, Canada.
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Ertmer C, Rehberg S, Morelli A, Westphal M. Current place of vasopressin analogues in the treatment of septic shock. Curr Infect Dis Rep 2008; 10:362-7. [DOI: 10.1007/s11908-008-0059-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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