Vasopressor-Sparing Strategies in Patients with Shock: A Scoping-Review and an Evidence-Based Strategy Proposition

Abstract

Despite the abundant literature on vasopressor therapy, few studies have focused on vasopressor-sparing strategies in patients with shock. We performed a scoping-review of the published studies evaluating vasopressor-sparing strategies by analyzing the results from randomized controlled trials conducted in patients with shock, with a focus on vasopressor doses and/or duration reduction. We analyzed 143 studies, mainly performed in septic shock. Our analysis demonstrated that several pharmacological and non-pharmacological strategies are associated with a decrease in the duration of vasopressor therapy. These strategies are as follows: implementing a weaning strategy, vasopressin use, systemic glucocorticoid administration, beta-blockers, and normothermia. On the contrary, early goal directed therapies, including fluid therapy, oral vasopressors, vitamin C, and renal replacement therapy, are not associated with an increase in vasopressor-free days. Based on these results, we proposed an evidence-based vasopressor management strategy.

Ventriculo-Arterial Coupling Is Associated With Oxygen Consumption and Tissue Perfusion in Acute Circulatory Failure

“…The fact that most uncoupled patients showed an increase in VO 2 after therapeutic interventions could be a further argument for targeting V-A coupling during resuscitation, as marker of tissular perfusion. This therapeutic option might help in better choosing the responsive patients, as a vasopressor-sparing strategy ( 32 ). The norepinephrine infusion alters V-A coupling with an increase in Ea >> Ev ( 30 , 33 ).…”

“…The norepinephrine infusion alters V-A coupling with an increase in Ea >> Ev ( 30 , 33 ). Targeting primarily the MAP of 65 mmHg might sustain an unnecessary ( 34 ) and possibly an unfavorable prolonged energetic state because of increased cardiac afterload ( 32 ). Algorithms using the monitoring dynamic arterial elastance were proposed in ICU and they demonstrated that early weaning of norepinephrine may be associated with better tissue perfusion ( 12 , 35 ).…”

Arterial Hypotension Following Norepinephrine Decrease in Septic Shock Patients Is Not Related to Preload Dependence: A Prospective, Observational Cohort Study

“…Vasopressor weaning is a dynamic process that requires a careful evaluation of the different components of the cardiovascular system ( 3 ). Physicians should consider the clinical benefit of fluid expansion in arterial hypotension during norepinephrine weaning.…”

“…Fluid therapy and norepinephrine are the main hemodynamic treatments for septic shock ( 1 , 2 ). Once the patient starts recovering, vascular tone progressively improves, and the hemodynamic de-escalation phase begins ( 1 , 3 ). Norepinephrine weaning is an important part of the therapeutic process when treating patients with septic shock ( 2 , 4 ).…”

Oral Water Has Cardiovascular Effects Up to 60 min in Shock Patients

“…Interesting most of the literature has focused on fluid during shock resuscitation but maintenance fluid therapy and creep fluid may account for 30% of fluid balance ( 28 ). Oral water may not replace iv fluid but it's long-acting cardiovascular effects may be of interest during optimization and weaning process of shock patients supported by vasopressor and fluid ( 29 ). In addition, using oral tap water may be of interest in term of fluid balance because plasma volume effect and body elimination can be modulated by adding glucose or combining different type of water (tap, saline, sugar).…”