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. 2015 Jul 14:11:1047-59.
doi: 10.2147/TCRM.S80060. eCollection 2015.

Vasopressors in septic shock: a systematic review and network meta-analysis

Feihu Zhou  1 , Zhi Mao  1 , Xiantao Zeng  2 , Hongjun Kang  1 , Hui Liu  1 , Liang Pan  1 , Peter C Hou  3
Affiliations

Vasopressors in septic shock: a systematic review and network meta-analysis

Feihu Zhou et al. Ther Clin Risk Manag. .

Abstract

Objective: Vasopressor agents are often prescribed in septic shock. However, their effects remain controversial. We conducted a systematic review and Bayesian network meta-analysis to compare the effects among different types of vasopressor agents.

Data sources: We searched for relevant studies in PubMed, Embase, and the Cochrane Library databases from database inception until December 2014.

Study selection: Randomized controlled trials in adults with septic shock that evaluated different vasopressor agents were selected.

Data extraction: Two authors independently selected studies and extracted data on study characteristics, methods, and outcomes.

Data synthesis: Twenty-one trials (n=3,819) met inclusion criteria, which compared eleven vasopressor agents or vasopressor combinations (norepinephrine [NE], dopamine [DA], vasopressin [VP], epinephrine [EN], terlipressin [TP], phenylephrine [PE], TP+NE, TP + dobutamine [DB], NE+DB, NE+EN, and NE + dopexamine [DX]). Except for the superiority of NE over DA, the mortality of patients treated with any vasopressor agent or vasopressor combination was not significantly different. Compared to DA, NE was found to be associated with decreased cardiac adverse events, heart rate (standardized mean difference [SMD]: -2.10; 95% confidence interval [CI]: -3.95, -0.25; P=0.03), and cardiac index (SMD: -0.73; 95% CI: -1.14, -0.03; P=0.004) and increased systemic vascular resistance index (SVRI) (SMD: 1.03; 95% CI: 0.61, 1.45; P<0.0001). This Bayesian meta-analysis revealed a possible rank of probability of mortality among the eleven vasopressor agents or vasopressor combinations; from lowest to highest, they are NE+DB, EN, TP, NE+EN, TP+NE, VP, TP+DB, NE, PE, NE+DX, and DA.

Conclusion: In terms of survival, NE may be superior to DA. Otherwise, there is insufficient evidence to suggest that any other vasopressor agent or vasopressor combination is superior to another. When compared to DA, NE is associated with decreased heart rate, cardiac index, and cardiovascular adverse events, as well as increased SVRI. The effects of vasopressor agents or vasopressor combinations on mortality in patients with septic shock require further investigation.

Keywords: dopamine; network meta-analysis; norepinephrine; sepsis; shock; vasopressors.

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Figures

Figure 1
Figure 1
Quorum chart of study cohort. Note: The search had been conducted using the PubMed, Embase, and the Cochrane Library databases from database inception to December 2014.
Figure 2
Figure 2
Network of eligible comparisons for the multiple-treatment meta-analysis for mortality. Notes: The width of the lines is proportional to the number of trials comparing each pair of treatments, and the size of each node is proportional to the number of randomized participants (sample size). The network of eligible comparisons for acceptability (dropout rate) analysis is similar. Abbreviations: DA, dopamine; DB, dobutamine; DX, dopexamine; EN, epinephrine; NE, norepinephrine; PE, phenylephrine; TP, terlipressin; VP, vasopressin.
Figure 3
Figure 3
Mortality of different vasopressors in direct comparison and network meta-analysis in terms of mortality. Notes: Results are the ORs and CIs in the row-defining treatment compared with the ORs and CIs in the column-defining treatment. For mortality, ORs >1 favor the row-defining treatment. Network meta-analysis results are at the bottom-left of the figure, while direct comparison results are at the upper-right of the figure. Abbreviations: CI, confidence interval; DA, dopamine; DB, dobutamine; DX, dopexamine; EN, epinephrine; NE, norepinephrine; NMA, network meta-analysis; OR, odds ratio; PE, phenylephrine; TP, terlipressin; VP, vasopressin.
Figure 4
Figure 4
Ranking for mortality. Notes: Ranking indicates the probability to be the most mortality risk treatment, the second best, the third best, and so on, among the vasopressor agents. Abbreviations: DA, dopamine; DB, dobutamine; DX, dopexamine; EN, epinephrine; NE, norepinephrine; PE, phenylephrine; TP, terlipressin; VP, vasopressin.
Figure 5
Figure 5
The cumulative probability plot. Notes: Area under the curve indicates the probability to be the most mortality risk treatment, the second best, the third best, and so on, among the vasopressor agents. Abbreviations: DA, dopamine; DB, dobutamine; DX, dopexamine; EN, epinephrine; NE, norepinephrine; PE, phenylephrine; TP, terlipressin; VP, vasopressin.
Figure 6
Figure 6
Inconsistency for triangular loops. Notes: acd: norepinephrine, vasopressin, and terlipressin comparison closed loop; afg: norepinephrine, terlipressin + dobutamine, and terlipressin + norepinephrine comparison closed loop. The values are shown as mean (confidence interval of inconsistency estimate). The symbol ■ indicates sample size.
See this image and copyright information in PMC

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