Evaluation of vasopressin use in the management of refractory shock in patients admitted to the intensive care unit





Shock; Critical care; Intensive care units; Vasopressins; Norepinephrine; Vasoconstrictor agents.


Refractory shock is characterized by hemodynamic instability unresponsive to norepinephrine with a high mortality rate. As there are still doubts regarding the pharmacological benefit of the vasopressin addition, this retrospective study aimed to assess the profile of vasopressin use in the intensive care unit of a university hospital in Paraná, Brazil. The information collected was obtained through the analysis of electronic medical records. 73 patients with refractory shock, mainly of septic etiology (61.6%), were included. The dose (μg/Kg/minute) and duration of norepinephrine, upon finding refractoriness, was 35.6% infusion < 1, 34, 3% of 1-1.9, 30.1% > 2 and mean time of 1.5 days. High mortality (80.8%) was observed, with a mean hospital stay of 8.2 days. Median survival after vasopressin infusion was 4.5 days until the unfavorable outcome. Still, 80.5% of patients used other adjuvant therapy, 71.2% being corticotherapy and 9.6% dobutamine. Due to the great variability, it was not possible to define a pattern of use. There were limitations in the analysis due to the lack of clinical and prognostic information. However, the need for deepening scientific discussions and continuous updating of protocols that guide management is highlighted.


Annane, D., Ouanes-Besbes, L., de Backer, D., DU, B., Gordon, A. C., Hernández, G., Olsen, K. M., Osborn, T. M., Peake, S., Russell, J. A., & Cavazzoni, S. Z. (2018). A global perspective on vasoactive agents in shock. Intensive care medicine, 44(6), 833–846. https://doi.org/10.1007/s00134-018-5242-5

Barola S, Shabbir N. Refractory Shock. [Updated 2021 Oct 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK564427/

Cui, N., Zhang, H., Chen, Z., & Yu, Z. (2019). Prognostic significance of PCT and CRP evaluation for adult ICU patients with sepsis and septic shock: retrospective analysis of 59 cases. The Journal of international medical research, 47(4), 1573–1579. https://doi.org/10.1177/0300060518822404

Duclos, G., Baumstarck, K., Dünser, M., Zieleskiewicz, L., & Leone, M. (2019). Effects of the discontinuation sequence of norepinephrine and vasopressin on hypotension incidence in patients with septic shock: A meta-analysis. Heart & lung : the journal of critical care, 48(6), 560–565. https://doi.org/10.1016/j.hrtlng.2019.05.007

Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., Belley-Cote, E., … Levy, M. (2021). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive care medicine, 47(11), 1181–1247. https://doi.org/10.1007/s00134-021-06506-y

Guinot, P.-G., Martin, A., Berthoud, V., Voizeux, P., Bartamian, L., Santangelo, E., Bouhemad, B., & Nguyen, M. (2021). Vasopressor-Sparing Strategies in Patients with Shock: A Scoping-Review and an Evidence-Based Strategy Proposition. Journal of Clinical Medicine, 10(14), 3164. https://doi.org/10.3390/jcm10143164

Hammond, D. A., Ficek, O. A., Painter, J. T., McCain, K., Cullen, J., Brotherton, A. L., Kakkera, K., Chopra, D., & Meena, N. (2018). Prospective Open-label Trial of Early Concomitant Vasopressin and Norepinephrine Therapy versus Initial Norepinephrine Monotherapy in Septic Shock. Pharmacotherapy, 38(5), 531–538. https://doi.org/10.1002/phar.2105

Huang, H., Wu, C., Shen, Q., Xu, H., Fang, Y., & Mao, W. (2021). The effect of early vasopressin use on patients with septic shock: A systematic review and meta-analysis. The American journal of emergency medicine, 48, 203–208. https://doi.org/10.1016/j.ajem.2021.05.007

Jentzer, J. C., Vallabhajosyula, S., Khanna, A. K., Chawla, L. S., Busse, L. W., & Kashani, K. B. (2018). Management of Refractory Vasodilatory Shock. Chest, 154(2), 416–426. https://doi.org/10.1016/j.chest.2017.12.021

Kądziołka, I., Świstek, R., Borowska, K., Tyszecki, P., & Serednicki, W. (2019). Validation of APACHE II and SAPS II scales at the intensive care unit along with assessment of SOFA scale at the admission as an isolated risk of death predictor. Anaesthesiology intensive therapy, 51(2), 107–111. https://doi.org/10.5114/ait.2019.86275

Kim, J. H., Sunkara, A., & Varnado, S. (2020). Management of Cardiogenic Shock in a Cardiac Intensive Care Unit. Methodist DeBakey cardiovascular journal, 16(1), 36–42. https://doi.org/10.14797/mdcj-16-1-36

Kislitsina, O. N., Rich, J. D., Wilcox, J. E., Pham, D. T., Churyla, A., Vorovich, E. B., Ghafourian, K., & Yancy, C. W. (2019). Shock - Classification and Pathophysiological Principles of Therapeutics. Current cardiology reviews, 15(2), 102–113. https://doi.org/10.2174/1573403X15666181212125024

Knotzer, H., Poidinger, B., & Kleinsasser, A. (2019). Pharmacologic Agents for the Treatment of Vasodilatory Shock. Current pharmaceutical design, 25(19), 2133–2139. https://doi.org/10.2174/1381612825666190704101907

Kny, K. T., Ferreira, M. A. P. & Pizzol, T. S. D. (2018). Use of vasopressin in the treatment of refractory septic shock. Revista Brasileira de Terapia Intensiva, 30(4), 423-428. Epub December 13, 2018.https://doi.org/10.5935/0103-507x.20180060

Mehta, S., Granton, J., Gordon, A. C., Cook, D. J., Lapinsky, S., Newton, G., Bandayrel, K., Little, A., Siau, C., Ayers, D., Singer, J., Lee, T. C., Walley, K. R., Storms, M., Cooper, D. J., Holmes, C. L., Hebert, P., Presneill, J., Russell, J. A., & Vasopressin and Septic Shock Trial (VASST) Investigators (2013). Cardiac ischemia in patients with septic shock randomized to vasopressin or norepinephrine. Critical care (London, England), 17(3), R117. https://doi.org/10.1186/cc12789

Meresse, Z., Medam, S., Mathieu, C., Duclos, G., Vincent, J. L., & Leone, M. (2020). Vasopressors to treat refractory septic shock. Minerva anestesiologica, 86(5), 537–545. https://doi.org/10.23736/S0375-9393.20.13826-4

Nakamura, K., Nakano, H., Naraba, H., Mochizuki, M., Takahashi, Y., Sonoo, T., Hashimoto, H., Abe, T., Hayakawa, M., & Yamakawa, K. (2021). Vasopressin Loading for Refractory Septic Shock: A Preliminary Analysis of a Case Series. Frontiers in medicine, 8, 644195. https://doi.org/10.3389/fmed.2021.644195

Patel, A., Beauchesne, A., Bredenkamp, N., McGloin, R., Stabler, S. N., & Boyce, K. (2020). Vasopressin for Septic Shock in a Medical-Surgical Intensive Care Unit. The Canadian journal of hospital pharmacy, 73(3), 209–21

Ríos-Toro, J. J., Márquez-Coello, M., García-Álvarez, J. M., Martín-Aspas, A., Rivera-Fernández, R., Sáez de Benito, A., & Girón-González, J. A. (2017). Soluble membrane receptors, interleukin 6, procalcitonin and C reactive protein as prognostic markers in patients with severe sepsis and septic shock. PloS one, 12(4), e0175254. https://doi.org/10.1371/journal.pone.0175254

Russell, J. A., Walley, K. R., Singer, J., Gordon, A. C., Hébert, P. C., Cooper, D. J., Holmes, C. L., Mehta, S., Granton, J. T., Storms, M. M., Cook, D. J., Presneill, J. J., Ayers, D., & VASST Investigators (2008). Vasopressin versus norepinephrine infusion in patients with septic shock. The New England journal of medicine, 358(9), 877–887. https://doi.org/10.1056/NEJMoa067373

Russell, J. A., Gordon, A. C., Williams, M. D., Boyd, J. H., Walley, K. R., & Kissoon, N. (2021). Vasopressor Therapy in the Intensive Care Unit. Seminars in respiratory and critical care medicine, 42(1), 59–77. https://doi.org/10.1055/s-0040-1710320

Standl, T., Annecke, T., Cascorbi, I., Heller, A. R., Sabashnikov, A., & Teske, W. (2018). The Nomenclature, Definition and Distinction of Types of Shock. Deutsches Arzteblatt international, 115(45), 757–768. https://doi.org/10.3238/arztebl.2018.0757

Thiele, H., Ohman, E. M., Desch, S., Eitel, I., & de Waha, S. (2015). Management of cardiogenic shock. European heart journal, 36(20), 1223–1230. https://doi.org/10.1093/eurheartj/ehv051

Udupa, A., & Shetty, R. (2018). Advanced cardiovascular support in refractory shock. Indian Journal of Respiratory Care, 7(2), 67. https://doi.org/10.4103/ijrc.ijrc_2_17

van Diepen, S., Katz, J. N., Albert, N. M., Henry, T. D., Jacobs, A. K., Kapur, N. K., Kilic, A., Menon, V., Ohman, E. M., Sweitzer, N. K., Thiele, H., Washam, J. B., Cohen, M. G., & American Heart Association Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; and Mission: Lifeline. (2017). Contemporary management of cardiogenic shock: A scientific statement from the American heart association. Circulation, 136(16), e232–e268. https://doi.org/10.1161/CIR.0000000000000525

Wu, K. S., Gu, D. Y., Wang, T. T., Yu, B. W., Pan, K. H., & Zhou, J. C. (2020). Factors associated with outcomes of septic shock patients receiving high

dose noradrenaline according to three primary infection sites. The Journal of international medical research, 48(2), 300060519874545. https://doi.org/10.1177/0300060519874545

Wu, Z., Zhang, S., Xu, J., Xie, J., Huang, L., Huang, Y., Yang, Y., & Qiu, H. (2020). Norepinephrine vs Vasopressin: Which Vasopressor Should Be Discontinued First in Septic Shock? A Meta-Analysis. Shock (Augusta, Ga.), 53(1), 50–57. https://doi.org/10.1097/SHK.0000000000001345




How to Cite

MACEDO, J. B. de; MIYOSHI, E.; BAGLIE, S.; D’HAESE, T. M. . Evaluation of vasopressin use in the management of refractory shock in patients admitted to the intensive care unit. Research, Society and Development, [S. l.], v. 11, n. 9, p. e12611932418, 2022. DOI: 10.33448/rsd-v11i9.32418. Disponível em: https://rsdjournal.org/index.php/rsd/article/view/32418. Acesso em: 16 aug. 2022.



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