Terlipressin or norepinephrine, or both in septic shock?

Vasopressin in Sepsis and Other Shock States: State of the Art

This review of the use of vasopressin aims to be comprehensive and highly practical, based on the available scientific evidence and our extensive clinical experience with the drug. It summarizes controversies about vasopressin use in septic shock and other vasodilatory states. Vasopressin is a natural hormone with powerful vasoconstrictive effects and is responsible for the regulation of plasma osmolality by maintaining fluid homeostasis. Septic shock is defined by the need for vasopressors to correct hypotension and lactic acidosis secondary to infection, with a high mortality rate. The Surviving Sepsis Campaign guidelines recommend vasopressin as a second-line vasopressor, added to norepinephrine. However, these guidelines do not address specific debates surrounding the use of vasopressin in real-world clinical practice.

Effects of Collagen Antibacterial Functional Dressing plus Continuous Nursing on Lower Extremity Skin Injury Caused by Norepinephrine in Patients with Septic Shock

Background

This study was designed to explore the effects of collagen antibacterial functional dressing plus continuous care on norepinephrine-induced lower extremity skin injury in patients with septic shock.

Methods

In this prospective, randomized, controlled study, 120 patients with septic shock receiving norepinephrine in our hospital from February 2020 to February 2021 were recruited. All the enrollments were randomized into the experimental group (n = 60) and the control group (n = 60). The control group received continuous care, while the experimental group additionally received collagen antibacterial functional dressing. Outcome measures included skin sensation scores, incidence of lower extremity skin injuries, recovery time, inflammatory factor levels, and care satisfaction.

Results

Collagen antibacterial functional dressing plus continuous care resulted in significantly lower skin sensation scores and a lower incidence of skin injuries versus continuous care alone. Patients in the experimental group had faster recovery of lower extremity skin injury than those in the control group. Collagen antibacterial functional dressing plus continuous care was associated with significantly lower levels of inflammatory factors and a higher satisfaction rate than continuous care alone.

Conclusion

Collagen antibacterial functional dressing plus continuous care improves the local skin condition of patients with septic shock receiving norepinephrine, regulates the levels of inflammatory factors, reduces the risk of skin injuries, and enhances care satisfaction.

Efficacy and safety of vasopressin and terlipressin in preterm neonates: a protocol for a systematic review

BACKGROUND

The use of vasoactive agents like arginine vasopressin (AVP) and terlipressin to treat hypotension or persistent pulmonary hypertension in critically ill preterm neonates is increasing. Therefore, a systematic review of the available data on dosing, efficacy and safety of AVP and terlipressin in this patient population appears beneficial.

METHODS

We will conduct a systematic review of the available evidence on the use of AVP and terlipressin for the treatment of hypotension or persistent pulmonary hypertension in preterm neonates. We will search Ovid MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science and Google Scholar from inception to March 2021. Two reviewers will independently screen titles and abstracts, review the full text of eligible studies, extract data, assess the risk of bias and judge the certainty of the evidence. Our primary outcome will be an (1) improvement of end-organ perfusion after initiation of AVP or terlipressin and (2) mortality prior to discharge. Our secondary outcomes will include (1) major neurosensory abnormality and (2) the occurrence of adverse events.

DISCUSSION

The currently available evidence on the efficacy and safety of AVP and terlipressin in preterm neonates is limited. Yet, evidence on the pharmacology of these drugs and the pathophysiology of vasoplegic shock support the biological plausibility for their clinical effectiveness in this population. Therefore, we aim to address this gap concerning the use of vasopressin and terlipressin among critically ill preterm neonates.

TRIAL REGISTRATION

This protocol has been submitted for registration to the international database of prospectively registered systematic reviews (PROSPERO, awaiting registration number).

Vasopressor Therapy in the Intensive Care Unit

After fluid administration for vasodilatory shock, vasopressors are commonly infused. Causes of vasodilatory shock include septic shock, post-cardiovascular surgery, post-acute myocardial infarction, postsurgery, other causes of an intense systemic inflammatory response, and drug -associated anaphylaxis. Therapeutic vasopressors are hormones that activate receptors-adrenergic: α1, α2, β1, β2; angiotensin II: AG1, AG2; vasopressin: AVPR1a, AVPR1B, AVPR2; dopamine: DA1, DA2. Vasopressor choice and dose vary widely because of patient and physician practice heterogeneity. Vasopressor adverse effects are excessive vasoconstriction causing organ ischemia/infarction, hyperglycemia, hyperlactatemia, tachycardia, and tachyarrhythmias. To date, no randomized controlled trial (RCT) of vasopressors has shown a decreased 28-day mortality rate. There is a need for evidence regarding alternative vasopressors as first-line vasopressors. We emphasize that vasopressors should be administered simultaneously with fluid replacement to prevent and decrease duration of hypotension in shock with vasodilation. Norepinephrine is the first-choice vasopressor in septic and vasodilatory shock. Interventions that decrease norepinephrine dose (vasopressin, angiotensin II) have not decreased 28-day mortality significantly. In patients not responsive to norepinephrine, vasopressin or epinephrine may be added. Angiotensin II may be useful for rapid resuscitation of profoundly hypotensive patients. Inotropic agent(s) (e.g., dobutamine) may be needed if vasopressors decrease ventricular contractility. Dopamine has fallen to almost no-use recommendation because of adverse effects; angiotensin II is available clinically; there are potent vasopressors with scant literature (e.g., methylene blue); and the novel V1a agonist selepressin missed on its pivotal RCT primary outcome. In pediatric septic shock, vasopressors, epinephrine, and norepinephrine are recommended equally because there is no clear evidence that supports the use of one vasoactive agent. Dopamine is recommended when epinephrine or norepinephrine is not available. New strategies include perhaps patients will be started on several vasopressors with complementary mechanisms of action, patients may be selected for particular vasopressors according to predictive biomarkers, and novel vasopressors may emerge with fewer adverse effects.

Efficacy and safety of Shenfu injection for septic shock: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the efficacy and safety of Shenfu injection (SFI) combined with standard therapy versus standard therapy for septic shock, three groups of patients with septic shock were analyzed based on the level of mean arterial lactate. They were mean arterial lactate level < 4.5 mmol/L, 4.5 mmol/L ≤ mean arterial lactate level < 7 mmol/L and mean arterial lactate level ≥ 7 mmol/L.

METHODS

Randomized controlled trials (RCT) from PubMed, Cochrane library, Embase, CENTRAL, SinoMed, Wanfang, CNKI, and Weipu (VIP) databases from the inception to September 2018 were searched. Relative risks (RR), weighted mean difference (WMD), along with 95% confidence interval (95%CI) were used to analyze the main outcomes. Statistical analysis was performed using Rev.Man 5.3. The qualities of the involved studies were accessed by the ROB according to the Cochrane handbook.

RESULTS

19 randomized controlled trials with 1505 participants were included. Compared with standard therapy, SFI plus standard therapy cannot decrease the 28-day mortality for all of the three groups. Compared with the other two subgroups (mean arterial lactate level < 4.5 mmol/L and mean arterial lactate level ≥ 7 mmol/L), the 4.5 mmol/L ≤ mean arterial lactate level < 7 mmol/L group has a trend to decrease 28-day mortality (RR: 0.67; 95% CI: 0.38-1.19; P = 0.17). In addition, adding SFI could have further increased mean arterial pressure (MAP) at 6-hours (RR: 7.05; 95% CI: 4.14-9.97) and further normalized heart rate (HR) when compared with standard therapy (RR: -17.48; 95% CI: [-19.39-(-15.57)].

CONCLUSION

For septic shock patients with 4.5 mmol/L ≤ mean arterial lactate level < 7 mmol/L, when the Traditional Chinese Medicine syndrome meet Yang-Qi deficiency, clinicians could choose SFI as a supplementary drug. But further high-quality and large-scale RCT should be performed to verify it.

PROSPERO REGISTRATION NUMBER

CRD42018090320.

Terlipressin for septic shock patients: a meta-analysis of randomized controlled study

Background

Catecholamines are commonly used in septic shock but face limitations of their hypo-responsiveness and adverse events due to high dose. Terlipressin is a synthetic vasopressin analog with greater selectivity for the V1-receptor. A meta-analysis was conducted to evaluate the efficacy and safety of terlipressin in septic shock.

Methods

We searched for relevant studies in PubMed, Embase, and the Cochrane database from inception up to July 15, 2018. Randomized controlled trials (RCTs) were included if they reported data on any of the predefined outcomes in patients with septic shock and managed with terlipressin or any catecholamines. Results were expressed as risk ratio (RR) or mean difference (MD) with accompanying 95% confidence interval (CI). Heterogeneity, subgroup analysis, sensitivity analysis, and publication bias were explored.

Results

Ten studies with 928 patients were included. Despite the shorter duration of mechanical ventilation, use of terlipressin did not reduce the risk of mortality (RR = 0.94; 95% CI, 0.85 to 1.05; I² = 0%; P = 0.28) when compared with control. This finding was confirmed by further subgroup and sensitivity analyses. In addition, lactate clearance, length of stay in ICU or hospital, total adverse events, digital ischemia, and arrhythmia were also similar between groups, while terlipressin was associated with shorter duration of mechanical ventilation and less norepinephrine requirements.

Conclusions

Current results suggest terlipressin did not show added survival benefit in septic shock therapy when compared with catecholamines.

Electronic supplementary material

The online version of this article (10.1186/s40560-019-0369-1) contains supplementary material, which is available to authorized users.