Vasopressin or norepinephrine in early hyperdynamic septic shock: a randomized clinical trial
To compare the effects of arginine-vasopressin (AVP) and norepinephrine (NE) on hemodynamic variables, organ dysfunction, and adverse events in early hyperdynamic septic shock.
Design and setting
Randomized, controlled, open-label trial.
Patients and participants
Twenty-three patients with early (12 h) hyperdynamic septic shock in two teaching hospitals.
AVP (0.04–0.20 U min–1, n = 13) as a single agent or NE (0.1–2.8 μg kg–1 min–1, n = 10) infusion for 48 h to achieve mean arterial pressure at or above 70 mmHg.
Measurements and results
Hemodynamic parameters and Sequential Organ Failure Assessment (SOFA) score were measured. AVP and NE equally increased mean arterial pressure over 48 h, but NE was required in 36% of AVP patients at 48 h. Compared to baseline, AVP increased systemic vascular resistance, decreased exposure to NE, decreased cardiac output by decreasing heart rate, increased creatinine clearance, and improved SOFA score. The PrCO2 – PaCO2 difference remained stable throughout the study. One AVP patient developed acute coronary syndrome with dose-dependent ECG changes. Three patients in both groups died during their ICU stay.
In early hyperdynamic septic shock, the administration of high-dose AVP as a single agent fails to increase mean arterial pressure in the first hour but maintains it above 70 mmHg in two-thirds of patients at 48 h. AVP decreases NE exposure, has no effect on the PrCO2 – PaCO2 difference, and improves renal function and SOFA score.
KeywordsVasopressin Norepinephrine Shock, septic Sepsis Kidney failure, acute Multiple organ failure
The authors thank Dr. Deborah Cook for reviewing the manuscript and Drs. Julie Abel, Dominique Bérard, Claude Cyr, Eric Deland, Sophie Laflamme, Marcel Martin, and Catherine St-Pierre for their help in recruiting patients.
- 1.Hoyert DL, Kung HC, Smith BL (2005) Deaths: preliminary data for 2003. Natl Vital Stat Rep 53:1–48Google Scholar
- 5.Müllner M, Urbanek B, Havel C, Losert H, Waechter F, Gamper G (2004) Vasopressors for shock. Cochrane Database of Systematic Reviews, issue 3: CD003709Google Scholar
- 20.American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference (1992) Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 20:864–874Google Scholar
- 21.Annane D, Sebille V, Charpentier C, Bollaert PE, Francois B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troche G, Chaumet-Riffaut P, Bellissant E (2002) Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288:862–871PubMedCrossRefGoogle Scholar
- 27.Moreno R, Vincent JL, Matos R, Mendonca A, Cantraine F, Thijs L, Takala J, Sprung C, Antonelli M, Bruining H, Willatts S (1999) The use of maximum SOFA score to quantify organ dysfunction/failure in intensive care. Results of a prospective, multicentre study. Intensive Care Med 25:686–696PubMedCrossRefGoogle Scholar
- 32.McVicar AJ (1988) Dose-response effects of pressor doses of arginine vasopressin on renal haemodynamics in the rat. J Physiol (Lond) 404:535–546Google Scholar