In this episode, I’ll discuss 4 changes to vasopressor recommendations in the 2021 Sepsis Guidelines.
The 2021 Sepsis Guidelines are out and there are some changes to vasopressor-related recommendations.
First, the wording for the MAP goal was slightly changed. It now reads:
For adults with septic shock on vasopressors, we recommend an initial target mean arterial pressure (MAP) of 65 mm Hg over higher MAP targets
Strong recommendation, moderate-quality evidence
This is slightly more specific than previous guidelines that didn’t include that the recommendation for a MAP of 65 was “over higher MAP targets”. This is in response to a study showing the lack of advantage associated with higher MAP targets and the lack of harm among elderly patients with MAP targets of 60–65 mm Hg vs a higher target.
Second, a remark was added to the section of the guidelines that discusses when to add vasopressin to norepinephrine. It now reads:
For adults with septic shock on norepinephrine with inadequate MAP levels, we suggest adding vasopressin instead of escalating the dose of norepinephrine
Weak recommendation, moderate-quality evidence
In our practice, vasopressin is usually started when the dose of norepinephrine is in the range of 0.25–0.5 μg/kg/min
This is useful information that clarifies practice and matches a recent study that I discussed in episode 650.
Third, specific information about starting vasopressors via peripheral IV access was added:
For adults with septic shock, we suggest starting vasopressors peripherally to restore MAP rather than delaying initiation until a central venous access is secured
Weak recommendation, very low quality of evidence
When using vasopressors peripherally, they should be administered only for a short period of time and in a vein in or proximal to the antecubital fossa
This makes sense as when the blood pressure is dangerously low from shock, the risk of phlebitis is outweighed by the potential life-saving effects of hemodynamic stabilization provided by vasopressors. For vasopressors I will use “any port in a storm” and then advocate for central access once the management priorities allow.
And finally, the word ‘phenylephrine’ no longer appears in the guidelines in any form. The 2016 guidelines said:
…the impact on clinical outcomes is uncertain, and phenylephrine use should be limited until more research is available.
Members of my Hospital Pharmacy Academy get access to a detailed breakdown of the new sepsis guidelines from a pharmacist’s point of view as well as access to hundreds of other trainings and resources to help you in your practice. To get immediate access go to pharmacyjoe.com/academy.
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