Skip to main content

Comment on “The Vasopressin Loading for Refractory septic shock (VALOR) study: a prospective observational study”

The Original Article was published on 21 July 2023

Dear Editor,

We read with interest the recent study by Nakamura et al., which investigated the potential use of a 1 U vasopressin bolus to indicate responses to continuous vasopressin infusion in septic shock patients [1]. The authors’ approach of segmenting patients into two groups based on a > 22 mmHg mean arterial pressure (MAP) change unveiled a considerable variation in the decrease of the catecholamine index. The team utilized the MAP response to vasopressin loading to forecast the catecholamine index reduction, a significant addition to our knowledge of vasopressor use.

In this multifaceted field, consensus is gradually forming around the benefits of a personalized multimodal strategy to maximize vasopressor use and maintain the MAP target [2]. Early evidence is amassing to validate this multimodal management [3, 4]. Nakamura et al.’s research aligns with this trend, and their innovative vasopressin administration technique is noteworthy. However, we propose several critical considerations.

First, the researchers permitted individual physicians to set the MAP target, providing MAP values only before and after vasopressin loading. This gap in the data raises questions, considering the primary outcome—the catecholamine index change six hours after vasopressin loading—is considerably influenced by MAP targets. The unpredictable fluctuations in blood pressure following vasopressin loading exacerbate these concerns. Therefore, providing specific data about MAP values six hours after loading would be beneficial.

Second, several key hemodynamic metrics, including the serum lactate level and norepinephrine dose, suggested that the responders were in a less severe stage of septic shock before vasopressin loading. While the study shows MAP changes post-vasopressin loading reliably predicted catecholamine index changes at six hours, such findings should be interpreted cautiously. Specifically, consideration should be given to the added predictive value of a holistic evaluation of hemodynamic status, which remains the gold standard.

Overall, Nakamura et al.’s research significantly contributes to the vasopressor therapy field. However, further studies are necessary to validate the findings and address the critical considerations raised.

Availability of data and materials

Not available.

References

  1. Nakamura K, Nakano H, Ikechi D, Mochizuki M, Takahashi Y, Koyama Y, et al. The Vasopressin Loading for Refractory septic shock (VALOR) study: a prospective observational study. Crit Care. 2023;27:294. https://doi.org/10.1186/s13054-023-04583-7.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Leone M, Einav S, Antonucci E, Depret F, Lakbar I, Martin-Loeches I, et al. Multimodal strategy to counteract vasodilation in septic shock. Anaesth Crit Care Pain Med. 2023;42:101193. https://doi.org/10.1016/j.accpm.2023.101193

  3. Wieruszewski PM, Bellomo R, Busse LW, Ham KR, Zarbock A, Khanna AK, et al. Initiating angiotensin II at lower vasopressor doses in vasodilatory shock: an exploratory post-hoc analysis of the ATHOS-3 clinical trial. Crit Care. 2023;27:175. https://doi.org/10.1186/s13054-023-04446-1.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Sacha GL, Lam SW, Wang L, Duggal A, Reddy AJ, Bauer SR. Association of catecholamine dose, lactate, and shock duration at vasopressin initiation with mortality in patients with septic shock. Crit Care Med. 2022;50:614–23. https://doi.org/10.1097/CCM.0000000000005317.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

Not applicable.

Author information

Authors and Affiliations

Authors

Contributions

YK and YH wrote and approved the final manuscript.

Corresponding author

Correspondence to Yuki Kotani.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kotani, Y., Hayashi, Y. Comment on “The Vasopressin Loading for Refractory septic shock (VALOR) study: a prospective observational study”. Crit Care 27, 324 (2023). https://doi.org/10.1186/s13054-023-04604-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13054-023-04604-5