Published online Dec 18, 2020. doi: 10.5492/wjccm.v9.i5.88
Peer-review started: August 1, 2020
First decision: September 17, 2020
Revised: October 10, 2020
Accepted: October 26, 2020
Article in press: October 26, 2020
Published online: December 18, 2020
Vasoplegic shock is a devastating complication post-surgery, in particular cardiac surgery, that leads to poor patient outcomes. Currently, treatment for this condition consists of norepinephrine and epinephrine. However, because of vasopressin’s unique pharmacology, it may have a role in the treatment of this condition.
Effective therapies aimed at hemodynamic preservation have not been identified in vasoplegic shock. Although norepinephrine and epinephrine are routine management, they have not proven all that effective for this condition given their hemodynamic profile and association with other complications. Vasopressin with its unique pharmacology and beneficial association with certain patient centered outcomes may be a reasonable first line alternative.
The aim of this systematic review was to summarize the available literature evaluating vasopressin vs non-vasopressin alternatives on patient-centered outcomes of vasoplegic shock in adult intensive care unit (ICU) patients. The aim of the present study will provide useful information on whether vasopressin maybe beneficial in the treatment of vasoplegic shock.
Randomized controlled trials, prospective cohorts, and retrospective cohorts comparing vasopressin to norepinephrine, epinephrine, methylene blue, hydroxocobalamin, or other pressors were included. The primary outcomes of interest were 30-d mortality, atrial/ventricular arrhythmias, stroke, ICU length of stay, duration of vasopressor therapy, incidence of acute kidney injury stage II-III, and mechanical ventilation for greater than 48 h. Given the mixed methodologies and heterogenous populations of the included studies and the overall small sample size, a meta-analysis was not conducted. We present weighted mean difference for continuous outcomes and relative risk for binary outcomes with associated confidence intervals.
A total of 1161 studies were screened for inclusion with 3 meeting inclusion criteria with a total of 708 patients. Two studies were randomized controlled trials and one was a retrospective cohort study. Primary outcomes of 30-d mortality, stroke, ventricular arrhythmias, and duration of mechanical ventilation were similar between groups. Conflicting results were observed for acute kidney injury stage II-III, atrial arrhythmias, duration of vasopressors, and ICU length of stay with higher certainty of evidence in favor of vasopressin serving a protective role for these outcomes. Although our results do not provide conclusive evidence of a beneficial role for vasopressin in the treatment of vasoplegic shock, we do provide some rationale as to why vasopressin could have a protective effect with regards to certain patient centered outcomes such as acute kidney injury, atrial arrhythmias, etc. We also provide some direction for future research in this area.
Vasopressin was not found to be superior to alternative pressor therapy for any of the included outcomes. Results are limited by mixed methodologies, small overall sample size, and heterogenous populations. We identify limitations in the present systematic review such as mixed methodologies and heterogeneous populations that preclude a definitive answer on the role of vasopressin in vasoplegic shock. Future studies should have more homogenous populations with similar methodologies so that a pooled analysis can be performed to definitively answer this question.
While current literature is promising, several questions still remain about vasopressin, such as ideal dosing strategies, timing of initiation, and in which patient populations vasopressin as a primary pressor may be ideal. Additional prospective multi-center research is warranted to investigate vasopressin’s role in improving patient-centered outcomes of post-operative vasoplegic shock on a large scale taking into consideration dosing strategies and timing of initiation of vasoactive agents.