Effect of synthetic vasopressin in septic shock using eosphageal Doppler

Introduction

Noradrenaline and dopamine were the standard catecholamines used in the treatment of septic shock. Loss of response was the common problem that led to patient loss after large continuous doses of noradrenaline, which was termed catecholamine refractory septic shock. Recently vasopressin and its analog, namely terlipressin, were used in the treatment of such a catastrophic condition.

Methods

In a prospective controlled study we included 40 patients with catecholamine-resistant septic shock (that is, noradrenaline dose exceeded 0.6 μg/kg/minute) divided into two groups: 20 patients were treated conventionally according to the Surviving Sepsis Campaign 2008, who served as a control group; and the other 20 patients were treated conventionally and when the noradrenaline dose exceeded 0.6 μg/kg/minute, terlipressin in a dose of 1 mg intravenous bolus every 12 hours for a study time of 48 hours was started.

Results

Terlipressin therapy was associated with increased systemic vascular resistance from 546 ± 260 dyne·sec/cm^-5 to 986 ± 390 dyne·sec/cm^-5 after 48 hours, which represents normalized arterilor tone that is expected to allow better organ bed perfusion. There was a reduction of both stroke volume and cardiac output (from 63 ± 16 ml/beat to 51 ml/beat and from 78 l/minute to 5.3 l/minute, respectively) yet this was not associated with abnormal organ perfusion marked by improved urine output from 49 ml/hour to 133 ml/hour and improved global perfusion as marked by decrease lactic acidosis from 9.3 ± 3 mEq/l to 5.7 ± 3 mEq/l, P < 0.002. There was significant reduction of oxygen delivery (DO₂ from 848 ml/minute to 610 ± 47 ml/minute after 48 hours, P > 0.02). There was no effect on length of ICU stay in both groups (16 ± 6 days in the terlipressin group and 12 ± 6 days in control group, P < 0.06). Terlipressin support showed nonsignificantly less mortality (60% vs 70% in control group). Regarding organ function, terlipressin could improve the SOFA score from 11 ± 3.2 to 8 ± 5 with P < 0.02.

Conclusions

Terlipressin is a rather safe, inexpensive, easy to administer alternative in the treatment of septic shock. Further studies are needed to decide the ideal timing for initiation of this therapy early vs late adjuvant or as an initial treatment.