1496: Impact of the Sequence of Norepinephrine and Vasopressin Discontinuation Post-Septic Shock

Bredhold, Benjamin E.; Winters, Shauna; Allen, Lauren; Callison, John C.; Heidel, Eric; Hamilton, Leslie A.

doi:10.1097/01.ccm.0000529498.33880.18

Cited by 2 publications

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“…Second, three studies were published only in the form of abstracts, with few variables, and can lead to omission bias by full data lacking . [17][18][19] Third, we observed a discrepancy between the retrospective studies and the randomized clinical trial, suggesting that our major finding was obtained from poor-quality studies. Finally, the definition of rebound hypotension differed among the included studies, with a variation in cut-off level (from 60 to 65 mmHg), interventions used (fluid bolus, increased vasopressor rate, etc.…”

Section: Discussionmentioning

confidence: 82%

“…This meta-analysis included nine original articles out of 650 screened publications that were retrieved by performing the literature search. [16][17][18][19][20][21][22][23][24] Of the nine included studies, three were abstracts that reported the results of retrospective analyses and six were full-text articles, including five retrospective studies and one randomized clinical trial. One study reported a protocol for vasopressor weaning.…”

Section: Search Results and Study Characteristicsmentioning

confidence: 99%

“…First, eight out of the nine studies included in this meta-analysis were retrospective studies with discrepancy in the amount of patients included in each studies. [16][17][18][19][20][21][22][23] Indeed, Sacha et al study represents more than 50% of the patients included in the norepinephrine group, with no difference between groups. We attempted to reduce this risk of bias with the sensitivity analysis.…”

Section: Discussionmentioning

confidence: 98%

“…Results of the sensitivity analysis by considering the quality of the studies (according to the 2016 revised Cochrane risk of bias tool) showed that risk was still significant (OR, 3.4; 95% CI, 1.3-8.6; p = 0.01). However, this effect was only observed when the four poor-quality studies were analyzed (OR, 5.4; 95% CI, 1.3-23.5; p = 0.02) [17][18][19][20] and was not observed when the five high-quality studies were analyzed (OR, 2.4; 95% CI, 0.6-8.4; p = 0.18). 16,[21][22][23][24]…”

Section: Primary End Pointmentioning

confidence: 91%

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Effects of the discontinuation sequence of norepinephrine and vasopressin on hypotension incidence in patients with septic shock: A meta-analysis

et al. 2019

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Section: Discussionmentioning

confidence: 82%

Section: Search Results and Study Characteristicsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 98%

Section: Primary End Pointmentioning

confidence: 91%

See 2 more Smart Citations

Effects of the discontinuation sequence of norepinephrine and vasopressin on hypotension incidence in patients with septic shock: A meta-analysis

et al. 2019

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Norepinephrine vs Vasopressin: Which Vasopressor Should Be Discontinued First in Septic Shock? A Meta-Analysis

Shi

et al. 2020

Shock

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Background: Patients with septic shock in whom norepinephrine (NE) infusion alone is insufficient to raise blood pressure require the concomitant administration of vasopressin (VP). However, current guidelines do not advise clinicians as to which vasoactive agent to discontinue first once the patient's septic shock begins to resolve. Moreover, there is controversial data guiding clinicians on how to discontinue vasopressors for septic shock patients who are receiving a combination therapy of NE and VP. Methods: The PubMed, EMBASE, and Cochrane Central Register databases were searched from the database inception until October 18, 2018. Studies were limited to adult patients with septic shock who received concomitant NE and VP treatment, that included different orders of vasopressor discontinuation. The primary outcome was the incidence of hypotension. Overall mortality, ICU mortality, and length of stay (LOS) in the ICU were secondary outcomes. Sensitivity and subgroup analyses as well as trial sequential analysis were performed. Results: One prospective randomized controlled trial and seven retrospective cohort studies were included in present meta-analysis. Compared with discontinuing VP first, the incidence of hypotension was significantly lower when NE was discontinued first (odds ratio, OR 0.3, 95% confidence interval, CI 0.10 to 0.86, P = 0.02; I 2 = 91%). No significant difference was detected in either overall mortality (OR 1.28, 95% CI 0.77 to 2.10, P = 0.34) or ICU mortality (OR 0.99, 95% CI 0.74 to 1.34, P = 0.96) between these two groups. Furthermore, ICU LOS was also evaluated in five studies, and no statistical significance was observed between the two groups with different orders in weaning vasopressors (mean difference 1.35, 95% CI −2.05 to 4.74, P = 0.44). The subgroup analyses suggested a significant association between hypotension and the practice of discontinuing VP first specifically in patients with a low usage rate of corticosteroids (odds ratio, OR 0.18, 95% confidence interval, CI 0.04 to 0.78, P = 0.02). The trial sequential analysis indicated a lack of sufficient evidence to draw conclusions from the current results (required information size = 11 821). Conclusions: In adults with septic shock treated with concomitant VP and NE therapy, discontinuing VP first may lead to a higher incidence of hypotension but is not associated with mortality or ICU LOS. Further prospective studies with larger sample sizes are warranted.

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1496: Impact of the Sequence of Norepinephrine and Vasopressin Discontinuation Post-Septic Shock

Cited by 2 publications

References 0 publications

Effects of the discontinuation sequence of norepinephrine and vasopressin on hypotension incidence in patients with septic shock: A meta-analysis

Effects of the discontinuation sequence of norepinephrine and vasopressin on hypotension incidence in patients with septic shock: A meta-analysis

Norepinephrine vs Vasopressin: Which Vasopressor Should Be Discontinued First in Septic Shock? A Meta-Analysis

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