Published online Jan 18, 2017. doi: 10.4254/wjh.v9.i2.106
Peer-review started: June 30, 2016
First decision: August 26, 2016
Revised: September 23, 2016
Accepted: December 1, 2016
Article in press: December 2, 2016
Published online: January 18, 2017
To examine patient-centered outcomes with vasopressin (AVP) use in patients with cirrhosis with catecholamine-refractory septic shock.
We conducted a single center, retrospective cohort study enrolling adult patients with cirrhosis treated for catecholamine-resistant septic shock in the intensive care unit (ICU) from March 2011 through December 2013. Other etiologies of shock were excluded. Multivariable regression models were constructed for seven and 28-d mortality comparing AVP as a second-line therapy to a group of all other vasoactive agents.
Forty-five consecutive patients with cirrhosis were treated for catecholamine-resistant septic shock; 21 received AVP while the remaining 24 received another agent [phenylephrine (10), dopamine (6), norepinephrine (4), dobutamine (2), milrinone (2)]. In general, no significant differences in baseline demographics, etiology of cirrhosis, laboratory values, vital signs or ICU mortality/severity of illness scores were observed with the exception of higher MELD scores in the AVP group (32.4, 95%CI: 28.6-36.2 vs 27.1, 95%CI: 23.6-30.6, P = 0.041). No statistically significant difference was observed in unadjusted 7-d (52.4% AVP vs 58.3% and P = 0.408) or 28-d mortality (81.0% AVP vs 87.5% non-AVP, P = 0.371). Corticosteroid administration was associated with lower 28-d mortality (HR = 0.37, 95%CI: 0.16-0.86, P = 0.021) independent of AVP use.
AVP is similar in terms of patient centered outcomes of seven and 28-d mortality, in comparison to all other vasopressors when used as a second line vasoactive agent in catecholamine resistant septic shock. Large-scale prospective study would help to refine current consensus standards and provide further support to our findings.
Core tip: Although the management of septic shock has evolved dramatically in recent decades, data regarding optimal vasopressor therapy in critically-ill patients with cirrhosis is less robust and is based largely on consensus expert opinion. We found no difference in 7-d or 28-d mortality with vasopressin use when compared to all other vasoactive agents as a second line agent in catecholamine-resistant septic shock. Further large-scale studies are needed to refine current consensus standards and provide further support to our findings.