Vasopressin versus Norepinephrine in Patients with Vasoplegic Shock after Cardiac Surgery

Abstract

Background Vasoplegic syndrome is a common complication after cardiac surgery and impacts negatively on patient outcomes. The objective of this study was to evaluate whether vasopressin is superior to norepinephrine in reducing postoperative complications in patients with vasoplegic syndrome. Methods This prospective, randomized, double-blind trial was conducted at the Heart Institute, University of Sao Paulo, Sao Paulo, Brazil, between January 2012 and March 2014. Patients with vasoplegic shock (defined as mean arterial pressure less than 65 mmHg resistant to fluid challenge and cardiac index greater than 2.2 l · min−2 · m−2) after cardiac surgery were randomized to receive vasopressin (0.01 to 0.06 U/min) or norepinephrine (10 to 60 μg/min) to maintain arterial pressure. The primary endpoint was a composite of mortality or severe complications (stroke, requirement for mechanical ventilation for longer than 48 h, deep sternal wound infection, reoperation, or acute renal failure) within 30 days. Results A total of 330 patients were randomized, and 300 were infused with one of the study drugs (vasopressin, 149; norepinephrine, 151). The primary outcome occurred in 32% of the vasopressin patients and in 49% of the norepinephrine patients (unadjusted hazard ratio, 0.55; 95% CI, 0.38 to 0.80; P = 0.0014). Regarding adverse events, the authors found a lower occurrence of atrial fibrillation in the vasopressin group (63.8% vs. 82.1%; P = 0.0004) and no difference between groups in the rates of digital ischemia, mesenteric ischemia, hyponatremia, and myocardial infarction. Conclusions The authors’ results suggest that vasopressin can be used as a first-line vasopressor agent in postcardiac surgery vasoplegic shock and improves clinical outcomes.

Cardiac and Vascular Surgery–Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group

“…Vasodilatory shock (vasoplegia) has become a common occurrence, particularly with the widespread use of angiotensin‐converting enzyme inhibitors and angiotensin receptor blockers . In a recent RCT of patients with vasoplegic shock (defined as mean arterial pressure <65 mm Hg resistant to fluid challenge and cardiac index >2.2 L/min per m 2 ) after cardiac surgery, vasopressin was associated with lower incidence of severe AKI (stages 2 and 3) and RRT use, although, again, study limitations prevent recommendation and further research is needed …”

Determinants and Outcomes of Vasoplegia Following Left Ventricular Assist Device Implantation

“…Similarly, our work indicates that reducing the time of CPB decreases the risk of developing vasoplegia. For patients who have already developed vasoplegia, a randomized clinical trial revealed that those who went on to receive vasopressin instead of norepinephrine had fewer postoperative complications . Furthermore, a literature review regarding the use of methylene blue (MB) as a treatment for vasoplegia confirmed that MB is safe if used within the recommended dosage and is useful for treating vasoplegia, although its benefit is time‐dependent .…”

Factors Associated with the Incidence and Severity of New-Onset Atrial Fibrillation in Adult Critically Ill Patients

“…It is speculated that one of the mechanisms of genesis of AF could be an excess of catecholamines or an increased sensitivity to them [19]. Vasopressin could also trigger AF [20], although it may have a lower ability to induce arrhythmias in critical patients [21, 22]. In our study, no patient in vasopressin use developed AF (Table 2 and Figure 1).…”