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Canadian Critical Care Society clinical practice guideline: The use of vasopressin and vasopressin analogues in critically ill adults with distributive shock

Recommandation de pratique clinique de la Société canadienne de soins intensifs: utilisation de vasopressine et d’analogues de la vasopressine chez l’adulte en état critique souffrant de choc distributif

Abstract

Purpose

Hemodynamic management of adults with distributive shock often includes the use of catecholamine-based vasoconstricting medications. It is unclear whether adding vasopressin or vasopressin analogues to catecholamine therapy is beneficial in the management of patients with distributive shock. The purpose of this guideline was to develop an evidence-based recommendation regarding the addition of vasopressin to catecholamine vasopressors in the management of adults with distributive shock.

Methods

We summarized the evidence informing this recommendation by updating a recently published meta-analysis. Then, a multidisciplinary panel from the Canadian Critical Care Society developed the recommendation using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.

Results

The updated systematic review identified 25 randomized controlled trials including a total of 3,737 patients with distributive shock. Compared with catecholamine therapy alone, the addition of vasopressin or its analogues was associated with a reduced risk of mortality (relative risk [RR], 0.91; 95% confidence interval [CI], 0.85 to 0.99; low certainty), reduced risk of atrial fibrillation (RR, 0.77; 95% CI, 0.67 to 0.88; high certainty), and increased risk of digital ischemia (RR, 2.56; 95% CI, 1.24 to 5.25; moderate certainty).

Conclusions

After considering certainty in the evidence, values and preferences, cost, and other factors, the expert guideline panel suggests using vasopressin or vasopressin analogues in addition to catecholamines over catecholamine vasopressors alone for the management of distributive shock (conditional recommendation, low certainty evidence).

Résumé

Objectif

La prise en charge hémodynamique des adultes atteints de choc distributif comprend souvent le recours à des agents vasoconstricteurs à base de catécholamines. Nous ne savons pas si l’ajout de vasopressine ou d’analogues de la vasopressine au traitement de catécholamines est bénéfique pour la prise en charge des patients atteints de choc distributif. L’objectif de cette ligne directrice était de mettre au point une recommandation fondée sur des données probantes concernant l’ajout de vasopressine aux vasopresseurs à base de catécholamines pour la prise en charge des adultes touchés par un choc distributif.

Méthode

Nous avons résumé les données probantes sur lesquelles se fonde cette recommandation en mettant à jour une méta-analyse publiée récemment. Par la suite, un panel multidisciplinaire de la Société canadienne de soins intensifs a mis au point une recommandation en se fondant sur la méthodologie GRADE (Grading of Recommendations, Assessment, Development, and Evaluation).

Résultats

La revue systématique mise à jour a identifié 25 études randomisées contrôlées, comptant un total de 3737 patients atteints de choc distributif. Par rapport à un traitement à base de catécholamines seulement, l’ajout de vasopressine ou de ses analogues a été associé à une réduction du risque de mortalité (risque relatif [RR], 0,91; intervalle de confiance [IC] 95 %, 0,85 à 0,99; certitude faible), une réduction du risque de fibrillation auriculaire (RR, 0,77; IC 95 %, 0,67 à 0,88; certitude forte), et une augmentation du risque d’ischémie digitale (RR, 2,56; IC 95 %, 1,24 à 5,25; certitude modérée).

Conclusion

Après avoir examiné le niveau de certitude des données probantes, les valeurs et préférences, le coût et d’autres facteurs, le panel d’experts pour l’élaboration des directives suggère d’utiliser des vasopressines ou des analogues de la vasopressine en plus des catécholamines, plutôt que seulement des vasopresseurs à base de catécholamines, pour la prise en charge du choc distributif (recommandation conditionnelle, données probantes de certitude faible).

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Author contributions

Bram Rochwerg chaired the guideline panel, helped to employ GRADE methodology and certainty of evidence assessments, and drafted the manuscript. Kimia Honarmand was the methods chair for the guideline panel and drafted the manuscript. Emilie Belley-Côté and Kevin Um led the systematic review team, and coordinated the evidence search and synthesis. All authors were panel members and contributed significantly to formulating the recommendation and providing edits to the manuscript.

Conflicts of interest

None declared.

Funding statement

Bram Rochwerg is supported by a Hamilton Health Sciences Early Career Research Award.

Editorial responsibility

This submission was handled by Dr. Hilary P. Grocott, Editor-in-Chief, Canadian Journal of Anesthesia.

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Correspondence to Bram Rochwerg MD, MSc.

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Honarmand, K., Um, K.J., Belley-Côté, E.P. et al. Canadian Critical Care Society clinical practice guideline: The use of vasopressin and vasopressin analogues in critically ill adults with distributive shock. Can J Anesth/J Can Anesth (2019) doi:10.1007/s12630-019-01546-x

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