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