The Combination of Vasopressin and Corticosteroids in Septic Shock: Cutting the mustard or a lemon in disguise? Emily Gordon, Pharm.D. PGY2 Critical Care Pharmacy Resident University Health System, San Antonio, Texas Division of Pharmacotherapy, The University of Texas at Austin College of Pharmacy Pharmacotherapy Education and Research Center, University of Texas Health Science Center at San Antonio September 12, 2014 Learning Objectives 1. Discuss the impact of septic shock on critically ill patients and current use of catecholamines for hemodynamic support. 2. Based on the current Surviving Sepsis Campaign guidelines, explain when the addition of vasopressin and/or corticosteroids is recommended in the management of septic shock. 3. Describe the potential interaction between vasopressin and corticosteroids in patients with septic shock. 4. Evaluate the use of vasopressin and corticosteroids as combination therapy in patients with septic shock.
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The Combination of Vasopressin and Corticosteroids
in Septic Shock: Cutting the mustard or a lemon in disguise?
Emily Gordon, Pharm.D.
PGY2 Critical Care Pharmacy Resident
University Health System, San Antonio, Texas
Division of Pharmacotherapy, The University of Texas at Austin College of Pharmacy
Pharmacotherapy Education and Research Center,
University of Texas Health Science Center at San Antonio
September 12, 2014
Learning Objectives
1. Discuss the impact of septic shock on critically ill patients and current use of catecholamines for
hemodynamic support.
2. Based on the current Surviving Sepsis Campaign guidelines, explain when the addition of vasopressin
and/or corticosteroids is recommended in the management of septic shock.
3. Describe the potential interaction between vasopressin and corticosteroids in patients with septic
shock.
4. Evaluate the use of vasopressin and corticosteroids as combination therapy in patients with septic
shock.
I. What is sepsis?1,2
a. Suspected or documented infection with systemic manifestations
i. Patient must meet
1. Temperature
2. Heart rate >
3. Respiratory rate >
4. White blood cell (WBC) count >
b. Can progress to severe sepsis and septic shock
Figure 1. Progression of sepsis
II. Severe sepsis and septic shock
a. Affects millions of people each year
b. Major health concern
i. Multi-organ dysfunction
ii. Major cause of mortality in intensive care unit (ICU) patients
1. Third most common cause of death in the U
neoplasm5
2. Mortality rates have decrease
3. Incidence of i
a. Mortality rate
i. Comorbidities
iii. Estimated annual U.S. healthcare system cost
III. Pathophysiologic changes5
a. Diffuse endothelial injury
i. Increased endothelial permeability due to shedding of the endothelial glycocalyx and
development of microvascular
ii. Leads to tissue and organ edema, hypotension, and shock
b. Vasoplegic shock
i. Distributive shock due to failure of vascular smooth muscle
ii. Leads to arterial and venodilatation
1. Decreases venous return
c. Myocardial depression
Sepsis
Suspected or documented infection with systemic manifestations (Figure 1)
Patient must meet ≥ 2 of systemic inflammatory response syndrome (SIRS) criteria
Temperature > 38°C or < 36°C
90 beats per minute
Respiratory rate > 20 per minute
White blood cell (WBC) count > 12,000/mm3, < 4,000/mm3, or >
Can progress to severe sepsis and septic shock
Progression of sepsis2
s and septic shock1,3,4
Affects millions of people each year
dysfunction
cause of mortality in intensive care unit (ICU) patients
Third most common cause of death in the U.S. after heart disease and malignant
Mortality rates have decreased steadily over last quarter century
Incidence of in-hospital mortality up to 50%4,5
Mortality rates vary depending on patient-specific factors
Comorbidities, infecting pathogen, site of infection, o
Estimated annual U.S. healthcare system cost of $24.3 billion7
Diffuse endothelial injury and altered microvascular flow
endothelial permeability due to shedding of the endothelial glycocalyx and
microvascular leak
tissue and organ edema, hypotension, and shock
Distributive shock due to failure of vascular smooth muscle constriction
Leads to arterial and venodilatation
venous return and compounds intravascular volume deficit
E. Gordon | 2
)
c inflammatory response syndrome (SIRS) criteria
, or > 10% bands
after heart disease and malignant
steadily over last quarter century6
specific factors
, organ dysfunction
endothelial permeability due to shedding of the endothelial glycocalyx and
constriction
ompounds intravascular volume deficit
E. Gordon | 3
Initial Management of Severe Sepsis
I. Focus on early management3,5
a. Speed and appropriateness of therapy likely influence outcomes
b. Early, aggressive administration of intravenous (IV) fluids, antibiotics, and vasoactive agents
II. Initial resuscitation1,3
a. Sepsis-induced tissue hypoperfusion
i. Hypotension persisting after initial fluid challenge
ii. Blood lactate concentration ≥ 4 mmol/L
b. Early goal-directed therapy3,8
i. Goals during the first 6 hours of resuscitation
1. Central venous pressure (CVP) 8-12 mm Hg
2. Mean arterial pressure (MAP) ≥ 65 mm Hg
3. Urine output ≥ 0.5 mL/kg/hr
4. Superior vena cava oxygenation saturation (ScvO2) ≥ 70% or mixed venous oxygen
saturation (SvO2) ≥ 65%
c. Normalization of elevated serum lactate (≤ 4 mmol/L)
III. Fluid therapy1
a. Adequate fluid resuscitation is a fundamental aspect of hemodynamic support
b. Crystalloids
i. Initial fluid of choice for resuscitation
ii. Fluid challenge should be administered to patients with sepsis-induced tissue
hypoperfusion
1. Minimum of 30 mL/kg of crystalloids
c. Colloids
i. May be considered in patients refractory to crystalloids
ii. Theoretical benefits over crystalloids
1. Antioxidant and anti-inflammatory effects
2. Ability to stabilize the endothelial glycocalyx
iii. No proven mortality difference in septic shock when compared to crystalloids9,10
IV. Antimicrobial therapy1
a. Cultures should be obtained prior to initiation of antimicrobial therapy
b. Effective IV antimicrobials within the first hour of severe sepsis and septic shock recognition
i. Each hour delay in antibiotic administration associated with measurable increase in
mortality (Figure 2)11
Figure 2. Survival impact of effective antimicrobial initiation following onset of septic shock
11
E. Gordon | 4
c. Initial empiric antimicrobial therapy
i. Should include ≥ 1 medication with activity against all likely pathogens and provide
adequate tissue penetration
ii. De-escalation should be performed as soon as susceptibility profile is known
d. Imaging studies to confirm potential source of infection
e. Source control, if possible, should be performed as rapidly as possible within the first 12 hours
after diagnosis
Role of Vasopressors
I. Vasopressor agents1
a. Used to target an initial MAP of ≥ 65 mm Hg
i. Goal to maintain perfusion during life-threatening hypotension
1. When MAP falls below autoregulatory threshold of critical vascular beds, organ
blood flow decreases linearly5
a. MAP < 60 mm Hg will likely result in ischemia of brain, heart, and kidney
ii. Optimal MAP should be individualized12
1. Higher MAP goals may be required in patients with atherosclerosis or chronic
hypertension
b. MAP endpoints should be supplemented with other markers of perfusion
i. Serum lactate concentrations, mental status, urine output, skin perfusion
c. Ideally, fluid resuscitation should be achieved before vasopressors and inotropes utilized
II. Vasopressor activity (Table 1)
Table 1. Vasopressor Receptor Activity13,14
α1 β1 β2 DA V1
Epinephrine +++ +++ ++
Norepinephrine +++ ++
Dopamine > 10a 5-10a < 5a
Phenylephrine ++++
Vasopressin +++ aApproximate affects based on dopamine dose in mcg/kg/min
DA=dopamine; V1=vasopressin-1 receptor
III. Choosing a vasopressor1,14
a. Dopamine (DA) versus norepinephrine (NE)
i. 2012 meta-analysis15
1. DA use associated with increased risk of death and development of arrhythmias as
compared with NE in patients with septic shock
b. Norepinephrine
i. First choice vasopressor
ii. α1-vasoconstrictive effects increase MAP with little change in heart rate or stroke volume
c. Dopamine
i. Alternative agent to NE only in select patients
1. Indicated in absolute or relative bradycardia
ii. Increases MAP and cardiac output
d. Epinephrine
i. Added or substituted for NE when additional agent needed to maintain adequate organ
perfusion
ii. Increases aerobic lactate production: stimulation of β2 receptors on skeletal muscles
e. Phenylephrine
i. Pure α-adrenergic effects
ii. Not recommended for the t
1. Decreases stroke volume
iii. May be used in select circumstance
1. Patients with serious arrhythmias associated with
2. High cardiac output with persistently low blood pressure
3. Salvage therapy when combined inotrope,
have failed to maintain MAP
IV. Vasopressin1,16,17
a. Used as adjunctive therapy to NE
i. Increase MAP
ii. Decrease catecholamine requirement
b. Physiology of endogenous
i. Vasopressin is releas
1. Release stimulated by hypotension
ii. Vasopressin acts on a variety of receptors
1. At vasopressin concentrations
vasopressin predominate
2. Little effect on arterial pressure
Table 2. Vasopressin Receptors
Receptor
V1
V2
V3
c. Physiology of vasopressin in septic shock
i. Acts as a stress hormone during hypotension
1. Vasopressin levels increase to maintain blood pressure via vasoconstriction
predominate V
2. Minimal antidiuretic effects in shock
Figure 3. Physiology of vasopressin
adrenergic effects: least likely to produce arrhythmias
Not recommended for the treatment of septic shock
stroke volume, cardiac output, renal and splanchnic blood flow
May be used in select circumstances
atients with serious arrhythmias associated with NE
High cardiac output with persistently low blood pressure
therapy when combined inotrope, vasopressor, and vasopressin
have failed to maintain MAP
Used as adjunctive therapy to NE
Decrease catecholamine requirement
endogenous vasopressin
Vasopressin is released into systemic circulation from posterior pituitary gland
Release stimulated by hypotension, hypovolemia, and hypernatremia
Vasopressin acts on a variety of receptors16 (Table 2)
vasopressin concentrations < 10 pg/mL, antidiuretic actions (V
vasopressin predominate
Little effect on arterial pressure (V1 receptor) at physiologic concentrations
. Vasopressin Receptors16
Primary Location
Vascular smooth muscle
Renal collecting duct
Pituitary and hippocampus
Physiology of vasopressin in septic shock17 (Figure 3)
Acts as a stress hormone during hypotension
Vasopressin levels increase to maintain blood pressure via vasoconstriction
predominate V1 receptor activity
Minimal antidiuretic effects in shock
Physiology of vasopressin17
E. Gordon | 5
, cardiac output, renal and splanchnic blood flow
, and vasopressin therapy
ed into systemic circulation from posterior pituitary gland
and hypernatremia
(V2 receptor) of
physiologic concentrations
Vasopressin levels increase to maintain blood pressure via vasoconstriction due to
E. Gordon | 6
d. Relative vasopressin deficiency in septic shock16
i. Endogenous vasopressin concentrations (Table 3)
1. Elevated early in septic shock
2. Decrease to normal ranges within 24 to 48 hours
a. Initially due to depletion of vasopressin stores in posterior pituitary
b. Vasopressin levels remain inappropriately low suggesting a sustained
impairment of vasopressin synthesis and release
i. Down-regulation of vasopressin production by excessive nitric oxide
release in posterior pituitary
3. Exogenous vasopressin infusion used to restore vasopressin concentrations