Vasopressin Initiation as a Second-Line VasoPressor in Early Septic Shock (VISPSS)

  • Ragoonanan, David PharmD, BCCCP
  • Nickelsen, Paige PharmD, BCCCP
  • Tran, Nicolas PharmD, BCPS, BCCCP
  • Allen, Bryan PharmD, BCCCP, BCIDP
  • Emborski, Rebecca PharmD, BCCCP
  • Legare, Anit PharmD, BCCCP
  • Vilella, Antonia PharmD, BCCCP
  • Hampson, Lauryn PharmD, BCPS, BCCCP
  • Busey, Kirsten PharmD, BCCCP
  • Shomo, Eileen PharmD, BCCCP
  • Broomfield, Abby PharmD
  • Hailu, Kirubel PharmD, BCPS, BCCCP

  • 1Department of Pharmacy Services, 7226Sarasota Memorial Hospital, Sarasota, FL, USA

    2Department of Pharmacy Services, 21814University of California San Diego, San Diego, CA, USA

    3Department of Pharmacy Services, 7829Tampa General Hospital, Tampa, FL, USA

    4Department of Pharmacy Services, 137661Ascension St. Vincent's, Jacksonville, FL, USA

David Ragoonanan, Trauma Pharmaceutical Care Specialist, Sarasota Memorial Healthcare System, 1700 S Tamiami Trail, Sarasota, FL 34239. Email: [email protected]

Journal of Intensive Care Medicine 39(4):p 306-312, April 2024. | DOI: 10.1177/08850666231201364

Background

Vasopressin is recommended as a second-line vasoactive agent for the management of septic shock; however, a paucity of data to guide its optimal use remains. The aim was to evaluate the effect of time-to vasopressin initiation and norepinephrine (NE) dose at vasopressin initiation on clinical outcomes in patients presenting with septic shock.

Methods

This was a multi-centered, retrospective, observational study conducted in patients with septic shock. Patients were divided into 2 groups: patients initiated on vasopressin when NE-equivalent dose (NEE) < 0.25 mcg/kg/min or ≥ 0.25 mcg/kg/min. The primary outcome was time-to-vasopressor discontinuation (hours). Secondary outcomes included 28-day in-hospital mortality, intensive care unit (ICU) length of stay (LOS), fluid balance after 72 hours, and the change in NEE at 12 hours.

Results

A total of 302 patients were included in this study. After propensity-score matching, 73 patients in each group were identified for analysis. There was no significant difference in the time-to-vasopressor discontinuation (hours) between the groups (88.8 [55–187.5] vs 86.7 [47–172]); p = 0.7815). Fluid balance (mL) at 72 hours was significantly lower when vasopressin was initiated at NEE < 0.25 mcg/kg/min (1769 [71–7287] vs 5762 [1463–8813]; p = 0.0077). A multivariable linear regression showed shorter time to shock resolution with earlier vasopressin initiation, defined as within 4 hours (p < 0.05).

Conclusion

In this propensity-score matched cohort, vasopressin initiation at NEE < 0.25 mcg/kg/min was not associated with shorter vasopressor duration. There was a lower fluid balance at 72 hours when vasopressin was initiated at lower NE doses.

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