In this episode, I’ll discuss vasopressin vs hydrocortisone as an adjunct to norepinephrine in sepsis.
When patients with septic shock require increasing doses of norepinephrine to maintain adequate perfusion, both hydrocortisone and vasopressin are potential second agents to add.
A group of authors recently published a multicenter, retrospective, observational study looking at patients with septic shock who had either hydrocortisone or vasopressin added as the next agent to help increase blood pressure.
Multivariable logistic regression and propensity score matching were used during analysis of the data in an effort to control for confounding factors.
Just over 750 patients were included in the analysis. The median norepinephrine dose at the time of initiation of the 2nd medication was 0.3 mcg/kg/min.
There was a statistically significant benefit on 28-day mortality in favor of adding hydrocortisone first to norepinephrine. The odds ratio for 28 day mortality was 0.46 when hydrocortisone was added first.
In addition to the mortality benefit, the hydrocortisone group did significantly better than the vasopressin group in rate of hemodynamic responsiveness, improved resolution of shock, and reduced recurrence of shock within 72 hours.
While the study was of an adequate size and multicenter in nature, it was also retrospective. This means that despite trying to control for potential confounders with statistical techniques, there may have been differences between the groups that were not accounted for. For example, the vasopressin group had a higher severity of illness. The authors conclude that these results should be hypothesis generating and inform the development of future prospective trials.
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