Vasopressin may show benefit in less severe shock in VASS trial

• ? Weans noradrenaline early
• ? Dose to low
• ? Harmful interaction

May reflect beneficial effects on renal function

VASS also suggested that vasopressin + steroids better than noradrenaline + steroids

Questions therefore

• Should we use earlier?
• Should we use higher doses?
• Should we use it with steroids

Factorial 2X2 double blinded RCT < 6/24

• Vasopressin 0.0-0.06 u/min OR noradrenaline 0-12mch/min
• When maxed out added either Hydrocort 50mg q6h or placebo

After this, open label catecholamines could be added but would be weaned first

Included adult septic patients, first episode of shock

Exclusions other reasons for steroids, CKD needing RRT

Primary outcome renal failure free days as defined by Stage 3 AKIN

414 randomised, even split

Matched groups

• Men > women
• APACHE mean 22
• 80-90% received noradrenaline pre-randomisation
• Usually included within 3/24
• Typical creatinine around 120-130

No difference in haemodynamics between the two groups but noradrenaline group needed more noradrenaline to do so

Fluid requirements and lactate concentrations much this same

Median creatinine level lower in vasopressin patients than noradrenaline

• No difference in distribution of renal failure
• No difference in survivors who ever developed renal failure
• No difference in non-survivors or survivors who did develop renal failure

No difference in mortality. No benefit to adding steroids.

Number of patients who required RRT was significantly lower (ARR 10%) than those who didn’t but once you needed dialysis, duration of that was the same

Conclusion: Early vasopressin maintained BP and reduced noradrenaline requirements as well as reducing the need for RRT but did not reduce the number of renal failure free days