Vasopressin Response and Clinical Trajectory in Septic Shock Patients

Abstract

Background In septic shock, vasopressors aim to improve tissue perfusion and prevent persistent organ dysfunction, a characteristic of chronic critical illness (CCI). Adjunctive vasopressin is often used to decrease catecholamine dosage, but the association of vasopressin response with subsequent patient outcomes is unclear. We hypothesized vasopressin response is associated with favorable clinical trajectory. Methods We included patients with septic shock receiving vasopressin as a catecholamine adjunct in this retrospective cohort study. We defined vasopressin response as a lowering of the catecholamine dose required to maintain mean arterial pressure ≥65 mm Hg, 6 h after vasopressin initiation. Clinical trajectories were adjudicated as early death (ED; death before day 14), CCI (ICU stay ≥14 days with persistent organ dysfunction), or rapid recovery (RR; not meeting ED or CCI criteria). Trajectories were placed on an ordinal scale with ED the worst outcome, CCI next, and RR the best outcome. The association of vasopressin response with clinical trajectory was assessed with multivariable ordinal logistic regression. Results In total 938 patients were included; 426 (45.4%) were vasopressin responders. The most frequent trajectory was ED (49.8%), 29.7% developed CCI, and 20.5% had rapid recovery. In survivors to ICU day 14 (those without ED), 59.2% had CCI and 40.8% experienced RR. Compared with vasopressin non-responders, vasopressin responders less frequently experienced ED (42.5% vs. 55.9%) and more frequently experienced RR (24.6% vs. 17.0%; P < 0.01). After controlling for confounders, vasopressin response was independently associated with higher odds of developing a better clinical trajectory (OR 1.63; 95% CI 1.26−2.10). Medical patients most frequently developed ED and survivors more commonly developed CCI than RR; surgical patients developed the three trajectories with similar frequency ( P < 0.01). Conclusions Vasopressin responsive status was associated with improved clinical trajectory in septic shock patients. Early vasopressin response is a potential novel prognostic marker for short-term clinical trajectory.

Surviving Sepsis Campaign Research Priorities 2023

“…Different subphenotypes of sepsis have been identified, but whether they warrant specific vasopressor support or other perfusion targets has yet to be discovered (155). Often the response to vasopressor agents is not taken into account when defining these subphenotypes, even though different trajectories are associated with different outcomes (156). Selecting patients responding to vasopressin may be achieved with the use of a loading dose (157), but this is less likely to occur with other vasopressor agents.…”

Argipressin-norepinephrine association in the treatment of septic shock: the use of the polydistrectual resistance index as an assessment of vascular compliance

“…Several models have been proposed to describe the interaction between argipressin and anti-inflammatory cytokine expression (13)(14)(15)(16)(17)(18)(19), which is suggestive of the immunomodulatory properties of argipressin (13). Patients with septic shock have reduced argipressin activity, and exogenous administration of argipressin can restore vascular tone and blood pressure, reducing the need for catecholamines (20)(21)(22)(23)(24)(25)(26).…”