Sacha et al (1) showed that vasopressin was utilized in 42.6% of acute kidney injury (AKI) before and increased to 54.6 % after rebranding, which seems to be high despite the cost increase. We reviewed potential justifications for the vasopressin increased use in AKI during septic shock (SS) after rebranding (2). Just after rebranding in 2016, Gordon et al (2) reported the results of the multicenter trial Vasopressin vs Norepinephrine as Initial Therapy in Septic Shock (VANISH), which compared the effect of these two vasopressors on AKI in adult patients with SS. Rationale for this study was the landmark Vasopressin and Septic Shock Trial (VASST), done in 2014 before rebranding. This study found an association between low-dose vasopressin (0.01-0.03 U/min) and decreased mortality in less severe SS but no difference between vasopressin and norepinephrine on global mortality or organ dysfunction rates (3). Post hoc analysis of the VASST study suggested that vasopressin treatment is associated with reduced progression to AKI, decreased need for renal replacement therapy (RRT), and reduced mortality in SS patients at risk of AKI (4). This concurred with earlier small clinical studies, demonstrating improvement in creatinine clearance (CCL) in vasopressin-treated patients (4). In the VANISH study, there were fewer RRTs in the vasopressin group (2).Unfortunately, the VANISH study did not find a difference in the number of kidney failure-free days in surviving patients receiving vasopressin or norepinephrine (2). The reduction in the number of RRTs in the vasopressin group but without any difference in the number of kidney failure-free days in survivors between groups had procured only some meager scientific solace (4). Many meta-analyses, however, did not reveal any significant improvements with vasopressin regarding AKI (4). Since rebranding, only one study has shown a favorable effect of vasopressin on AKI risk in sepsis. This was a study performed in an ovine model of sepsis by Okazaki et al (5). This study showed that vasopressin infusion did not significantly affect renal medullary perfusion or Po 2 and induced a sustained (6 hr) ~2.5-fold increase in CCL (5). Vasopressin reduced sepsis-induced mesenteric hyperemia (+61 ± 13 to +9% ± 6%) (5). Norepinephrine transiently (2 hr) improved CCL (by ~3.5-fold) but worsened renal medullary ischemia (to -64% ± 7%) and hypoxia (to -71% ± 6%) (5). Therefore, clearly, low-dose vasopressin (0.03 international units [IU]/min [0.03-0.05 IU/min]) as first vasopressor

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The optimization of patients’ treatment in the intensive care unit (ICU) needs a lot of information and literature analysis. Many changes have been made in the last years to help evaluate sedated patients by scores to help take care of them. Patients were completely sedated and had continuous intravenous analgesia and neuromuscular blockades. These three drug classes were the main drugs used for intubated patients in the ICU. During these last 20 years, ICU management went from fully sedated to awake, calm, and nonagitated patients, using less sedatives and choosing other drugs to decrease the risks of delirium during or after the ICU stay. Thus, the usefulness of these three drug classes has been challenged. The analgesic drugs used were primarily opioids but the use of other drugs instead is increasing to lessen or wean the use of opioids. In severe acute respiratory distress syndrome patients, neuromuscular blocking agents have been used frequently to block spontaneous respiration for 48 hours or more; however, this has recently been abolished. Optimizing a patient's comfort during hemodynamic or respiratory extracorporeal support is essential to reduce toxicity and secondary complications.