The Therapeutic Role of Vasopressin on Improving lactate Clearance During and After Vasogenic Shock: Microcirculation, Is It The Black Box?
Arginine vasopressin as a supplementary vasopressor in septic shock restores vascular tone and mean arterial pressure, meanwhile decreases dose and exposure time to catecholamines. The objective of this study was to evaluate the effect of vasopressin on lactate and lactate clearance as markers of tissue perfusion during septic shock. In this prospective, randomized, controlled trial, 30 patients with septic shock were enrolled in two groups. One group received norepinephrine infusion (titrated to reach the target MAP of ≥65 mm Hg) and the other group in addition to norepinephrine, received vasopressin at a constant rate of 0.03 u/min. Serum lactate levels were assessed at baseline, 24 and 48 hours after randomization. Lactate clearance was estimated for each patient at 24 and 48 hours. Venous lactate was measured in both groups. Despite a tendency toward higher venous lactate at 24 and 48 hours in the norepinephrine group (3.1 vs. 2.5, P=0.67 and 1.7 vs. 1.1, P=0.47), the conflict was not statistically significant among them. While lactate clearance after 24 hours was significantly higher in vasopressin treatment group (46% vs. 20%, respectively; P=0.048), the 48-hour lactate clearance did not differ from statistic viewpoints despite their clinical values (66% vs. 40%, P=0.17). Although lactate levels did not significantly differ between treatment groups, lactate clearance at 24 hours was significantly higher in vasopressin group. This may be the effect of vasopressin effect on microcirculation and tissue hypoperfusion or its catecholamine sparing effect.
Kampmeier TG, Rehberg S, Westphal M, et al. Vasopressin in sepsis and septic shock. Minerva Anestesiol 2010;76(10):844-50.
Farand P, Hamel M, Lauzier F, et al. Review article: organ perfusion/permeability-related effects of norepinephrine and vasopressin in sepsis. Can J Anaesth 2006;53(9):934-46.
Gordon A. Vasopressin in septic shock. J Intens Care Soc 2011;12(1):11-4.
Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 2013;39(2):165-228.
Holmes CL, Patel BM, Russell JA, et al. Physiology of vasopressin relevant to management of septic shock. Chest 2001;120(3):989-1002.
Reardon DP, Degrado JR, Anger KE, et al. Early vasopressin reduces incidence of new onset arrhythmias. J Crit Care 2014;29(4):482-5.
Friedrich JO, Wilson G, Chant C. Long-term outcomes and clinical predictors of hospital mortality in very long stay intensive care unit patients: a cohort study. Crit Care 2006;10(2):R59.
Schmidt GA, Mandel J. Evaluation and management of severe sepsis and septic shock in adults. In: UpToDate, Post TW, editors. UpToDate. Waltham, MA.
Hollenberg SM. Inotrope and vasopressor therapy of septic shock. Crit Care Clin 2009;25(4):781-802, ix.
Faix JD. Biomarkers of sepsis. Crit Rev Clin Lab Sci 2013;50(1):23-36.
Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 1992;101(6):1644-55.
Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 1993;270(24):2957-63.
Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsisrelated Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 1996;22(7):707-10.
Nguyen HB, Rivers EP, Knoblich BP, et al. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med 2004;32(8):1637-42.
Arnold RC, Shapiro NI, Jones AE, et al. Multicenter study of early lactate clearance as a determinant of survival in patients with presumed sepsis. Shock 2009;32(1):35-9.
Russell JA, Walley KR, Singer J, et al. Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med 2008;358(9):877-87.
Torgersen C, Dunser MW, Wenzel V, et al. Comparing two different arginine vasopressin doses in advanced vasodilatory shock: a randomized, controlled, open-label trial. Intensive Care Med 2010;36(1):57-65.
Cartotto R, McGibney K, Smith T, et al. Vasopressin for the septic burn patient. Burns 2007;33(4):441-51.
Luckner G, Mayr VD, Jochberger S, et al. Comparison of two dose regimens of arginine vasopressin in advanced vasodilatory shock. Crit Care Med 2007;35(10):2280-5.
Dunser MW, Werner ER, Wenzel V, et al. Arginine vasopressin and serum nitrite/nitrate concentrations in advanced vasodilatory shock. Acta Anaesthesiol Scand 2004;48(7):814-9.
Dunser MW, Mayr AJ, Ulmer H, et al. Arginine vasopressin in advanced vasodilatory shock: a prospective, randomized, controlled study. Circulation 2003;107(18):2313-9.
Patel BM, Chittock DR, Russell JA, et al. Beneficial effects of short-term vasopressin infusion during severe septic shock. Anesthesiology 2002;96(3):576-82.
Dunser MW, Mayr AJ, Ulmer H, et al. The effects of vasopressin on systemic hemodynamics in catecholamineresistant septic and postcardiotomy shock: a retrospective analysis. Anesth Analg 2001;93(1):7-13.
Middleton P, Kelly AM, Brown J, et al. Agreement between arterial and central venous values for pH, bicarbonate, base excess, and lactate. Emerg Med J 2006;23(8):622-4.
Zhou FH, Song Q. Clinical trials comparing norepinephrine with vasopressin in patients with septic shock: a meta-analysis. Mil Med Res 2014;1:6.
Luckner Gn, Dunser MW, Jochberger S, et al. Arginine vasopressin in 316 patients with advanced vasodilatory shock. Crit Care Med 2005;33(11):2659-66.
Jones AE, Puskarich MA. Sepsis-induced tissuehypoperfusion. Crit Care Nurs Clin North Am 2009;25(4):769-79.
Walker CA, Griffith DM, Gray AJ, et al. Early lactate clearance in septic patients with elevated lactate levels admitted from the emergency department to intensive care: time to aim higher? J Crit Care 2013;28(5):832-7.
Hernandez G, Castro R, Romero C, et al. Persistent sepsisinduced hypotension without hyperlactatemia: is it really septic shock? J Crit Care 2011;26(4):435.e9-14.
Wacharasint P, Nakada TA, Boyd JH, et al. Normal-range blood lactate concentration in septic shock is prognostic and predictive. Shock 2012;38(1):4-10.
Jones AE, Shapiro NI, Trzeciak S, et al. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA2010;303(8):739-46.
Jansen TC, van Bommel J, Schoonderbeek FJ, et al. Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. Am J Respir Crit Care Med 2010;182(6):752-61.
Tian HH, Han SS, Lv CJ, et al. The effect of early goal lactate clearance rate on the outcome of septic shock patients with severe pneumonia. Zhongguo wei zhong bing ji jiu yi xue 2012;24(1):42-5.
Nguyen HB, Kuan WS, Batech M, et al. Outcome effectiveness of the severe sepsis resuscitation bundle withaddition of lactate clearance as a bundle item: a multinational evaluation. Crit Care 2011;15(5):R229.
Levy B. Bench-to-bedside review: Is there a place for epinephrine in septic shock? Crit Care 2005;9(6):561-5.
Ertmer C, Bone HG, Morelli A, et al. Methylprednisolone reverses vasopressin hyporesponsiveness in ovine endotoxemia. Shock 2007;27(3):281-8.
Russell JA. Bench-to-bedside review: Vasopressin in the management of septic shock. Crit Care 2011;15(4):226.
Klinzing S, Simon M, Reinhart K, et al. High-dose vasopressin is not superior to norepinephrine in septic shock. Crit Care Med 2003;31(11):2646-50.
Westphal M, Freise H, Kehrel BE, et al. Arginine vasopressin compromises gut mucosal microcirculation in septic rats. Crit Care Med 2004;32(1):194-200.
Lange M, Morelli A, Ertmer C, et al. Continuous versusbolus infusion of terlipressin in ovine endotoxemia. Shock 2007;28(5):623-9.
Miller JT, Welage LS, Kraft MD, et al. Does body weightimpact the efficacy of vasopressin therapy in the management of septic shock? J Crit Care 2012;27(3):289-93.
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