Current use of vasopressors in septic shock

Thomas W L Scheeren¹, Jan Bakker^{2

3

4

5}, Daniel De Backer⁶, Djillali Annane⁷, Pierre Asfar⁸, E Christiaan Boerma⁹, Maurizio Cecconi¹⁰, Arnaldo Dubin¹¹, Martin W Dünser¹², Jacques Duranteau¹³, Anthony C Gordon¹⁴, Olfa Hamzaoui¹⁵, Glenn Hernández¹⁶, Marc Leone¹⁷, Bruno Levy¹⁸, Claude Martin¹⁷, Alexandre Mebazaa¹⁹, Xavier Monnet^{20

21}, Andrea Morelli²², Didier Payen²³, Rupert Pearse²⁴, Michael R Pinsky²⁵, Peter Radermacher²⁶, Daniel Reuter²⁷, Bernd Saugel²⁸, Yasser Sakr²⁹, Mervyn Singer³⁰, Pierre Squara³¹, Antoine Vieillard-Baron^{32

33}, Philippe Vignon³⁴, Simon T Vistisen³⁵, Iwan C C van der Horst³⁶, Jean-Louis Vincent³⁷, Jean-Louis Teboul³⁸

Affiliations

¹ Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700RB, Groningen, The Netherlands. t.w.l.scheeren@umcg.nl.
² New York University Medical Center, New York, USA.
³ Columbia University Medical Center, New York, USA.
⁴ Erasmus MC University Medical Center, Rotterdam, Netherlands.
⁵ Pontificia Universidad Católica de Chile, Santiago, Chile.
⁶ Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium.
⁷ Department of Intensive Care Medicine, School of Medicine Simone Veil, Raymond Poincaré Hospital (APHP), University of Versailles-University Paris Saclay, 104 boulevard Raymond Poincaré, 92380, Garches, France.
⁸ Département de Médecine Intensive-Réanimation et de Médecine Hyperbare, Centre Hospitalier Universitaire Angers, Institut MITOVASC, CNRS, UMR 6214, INSERM U1083, Angers University, Angers, France.
⁹ Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands.
¹⁰ Department of Anaesthesia and Intensive Care Units, Humanitas Research Hospital and Humanitas University, Milan, Italy.
¹¹ Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata y Servicio de Terapia Intensiva, Sanatorio Otamendi, Buenos Aires, Argentina.
¹² Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University Linz, Linz, Austria.
¹³ Assistance Publique des Hopitaux de Paris, Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France.
¹⁴ Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK.
¹⁵ Assistance Publique-Hôpitaux de Paris Paris-Sud University Hospitals, Intensive Care Unit, Antoine Béclère Hospital, Clamart, France.
¹⁶ Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
¹⁷ Assistance Publique Hôpitaux de Marseille, Service d'Anesthésie et de Réanimation CHU Nord, Aix Marseille Université, Marseille, France.
¹⁸ Service de Réanimation Médicale Brabois et pôle cardio-médico-chirurgical, CHRU, INSERM U1116, Université de Lorraine, Brabois, 54500, Vandoeuvre les Nancy, France.
¹⁹ Department of Anesthesia, Burn and Critical Care, APHP Hôpitaux Universitaires Saint Louis Lariboisière, U942 Inserm, Université Paris Diderot, Paris, France.
²⁰ Assistance Publique-Hôpitaux de Paris, Paris-Sud University Hospitals, Medical Intensive Care Unit, Bicêtre Hospital, Le Kremlin-Bicêtre, France.
²¹ INSERM UMR_S 999, Paris-Saclay University, Le Plessis-Robinson, France.
²² Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome "La Sapienza", Rome, Italy.
²³ INSERM 1160 and Hôpital Lariboisière, APHP, University Paris 7 Denis Diderot, Paris, France.
²⁴ Queen Mary University of London, London, UK.
²⁵ Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA.
²⁶ Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Ulm, Germany.
²⁷ Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Centre, Rostock, Germany.
²⁸ Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
²⁹ Department of Anesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany.
³⁰ Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK.
³¹ ICU Department, Réanimation CERIC, Clinique Ambroise Paré, Neuilly, France.
³² Assistance Publique-Hôpitaux de Paris, Intensive Care Unit, University Hospital Ambroise Paré, Boulogne-Billancourt, France.
³³ INSERM U-1018, CESP, Team 5, University of Versailles Saint-Quentin en Yvelines, Villejuif, France.
³⁴ Medical-Surgical Intensive Care Unit, INSERM CIC-1435, Teaching Hospital of Limoges, University of Limoges, Limoges, France.
³⁵ Institute of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
³⁶ Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
³⁷ Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
³⁸ Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, France.

PMID: 30701448
PMCID: PMC6353977
DOI: 10.1186/s13613-019-0498-7

Current use of vasopressors in septic shock

Thomas W L Scheeren et al. Ann Intensive Care. 2019.

. 2019 Jan 30;9(1):20.

doi: 10.1186/s13613-019-0498-7.

Authors

Affiliations

¹ Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700RB, Groningen, The Netherlands. t.w.l.scheeren@umcg.nl.
² New York University Medical Center, New York, USA.
³ Columbia University Medical Center, New York, USA.
⁴ Erasmus MC University Medical Center, Rotterdam, Netherlands.
⁵ Pontificia Universidad Católica de Chile, Santiago, Chile.
⁶ Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium.
⁷ Department of Intensive Care Medicine, School of Medicine Simone Veil, Raymond Poincaré Hospital (APHP), University of Versailles-University Paris Saclay, 104 boulevard Raymond Poincaré, 92380, Garches, France.
⁸ Département de Médecine Intensive-Réanimation et de Médecine Hyperbare, Centre Hospitalier Universitaire Angers, Institut MITOVASC, CNRS, UMR 6214, INSERM U1083, Angers University, Angers, France.
⁹ Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands.
¹⁰ Department of Anaesthesia and Intensive Care Units, Humanitas Research Hospital and Humanitas University, Milan, Italy.
¹¹ Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata y Servicio de Terapia Intensiva, Sanatorio Otamendi, Buenos Aires, Argentina.
¹² Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University Linz, Linz, Austria.
¹³ Assistance Publique des Hopitaux de Paris, Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France.
¹⁴ Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK.
¹⁵ Assistance Publique-Hôpitaux de Paris Paris-Sud University Hospitals, Intensive Care Unit, Antoine Béclère Hospital, Clamart, France.
¹⁶ Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
¹⁷ Assistance Publique Hôpitaux de Marseille, Service d'Anesthésie et de Réanimation CHU Nord, Aix Marseille Université, Marseille, France.
¹⁸ Service de Réanimation Médicale Brabois et pôle cardio-médico-chirurgical, CHRU, INSERM U1116, Université de Lorraine, Brabois, 54500, Vandoeuvre les Nancy, France.
¹⁹ Department of Anesthesia, Burn and Critical Care, APHP Hôpitaux Universitaires Saint Louis Lariboisière, U942 Inserm, Université Paris Diderot, Paris, France.
²⁰ Assistance Publique-Hôpitaux de Paris, Paris-Sud University Hospitals, Medical Intensive Care Unit, Bicêtre Hospital, Le Kremlin-Bicêtre, France.
²¹ INSERM UMR_S 999, Paris-Saclay University, Le Plessis-Robinson, France.
²² Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome "La Sapienza", Rome, Italy.
²³ INSERM 1160 and Hôpital Lariboisière, APHP, University Paris 7 Denis Diderot, Paris, France.
²⁴ Queen Mary University of London, London, UK.
²⁵ Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA.
²⁶ Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Ulm, Germany.
²⁷ Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Centre, Rostock, Germany.
²⁸ Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
²⁹ Department of Anesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany.
³⁰ Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK.
³¹ ICU Department, Réanimation CERIC, Clinique Ambroise Paré, Neuilly, France.
³² Assistance Publique-Hôpitaux de Paris, Intensive Care Unit, University Hospital Ambroise Paré, Boulogne-Billancourt, France.
³³ INSERM U-1018, CESP, Team 5, University of Versailles Saint-Quentin en Yvelines, Villejuif, France.
³⁴ Medical-Surgical Intensive Care Unit, INSERM CIC-1435, Teaching Hospital of Limoges, University of Limoges, Limoges, France.
³⁵ Institute of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
³⁶ Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
³⁷ Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
³⁸ Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, France.

PMID: 30701448
PMCID: PMC6353977
DOI: 10.1186/s13613-019-0498-7

Abstract

Background: Vasopressors are commonly applied to restore and maintain blood pressure in patients with sepsis. We aimed to evaluate the current practice and therapeutic goals regarding vasopressor use in septic shock as a basis for future studies and to provide some recommendations on their use.

Methods: From November 2016 to April 2017, an anonymous web-based survey on the use of vasoactive drugs was accessible to members of the European Society of Intensive Care Medicine (ESICM). A total of 17 questions focused on the profile of respondents, triggering factors, first choice agent, dosing, timing, targets, additional treatments, and effects of vasopressors. We investigated whether the answers complied with current guidelines. In addition, a group of 34 international ESICM experts was asked to formulate recommendations for the use of vasopressors based on 6 questions with sub-questions (total 14).

Results: A total of 839 physicians from 82 countries (65% main specialty/activity intensive care) responded. The main trigger for vasopressor use was an insufficient mean arterial pressure (MAP) response to initial fluid resuscitation (83%). The first-line vasopressor was norepinephrine (97%), targeting predominantly a MAP > 60-65 mmHg (70%), with higher targets in patients with chronic arterial hypertension (79%). The experts agreed on 10 recommendations, 9 of which were based on unanimous or strong (≥ 80%) agreement. They recommended not to delay vasopressor treatment until fluid resuscitation is completed but rather to start with norepinephrine early to achieve a target MAP of ≥ 65 mmHg.

Conclusion: Reported vasopressor use in septic shock is compliant with contemporary guidelines. Future studies should focus on individualized treatment targets including earlier use of vasopressors.

Keywords: Arterial blood pressure; Norepinephrine; Resuscitation; Sepsis; Septic shock; Shock; Vasoactive agonists; Vasopressor.

PubMed Disclaimer

Figures

**Fig. 1**
RAND algorithm. Method used to define the degree of consensus and grades of recommendations of the experts’ recommendations

**Fig. 2**
a Survey respondents from European countries. Number of survey respondents working in European countries. Black bars indicate high-income countries, and white bars lower-income countries. b Survey respondents from Non-European countries. Number of survey respondents working in Non-European countries. Black bars indicate high-income countries, and white bars lower-income countries

See this image and copyright information in PMC

References

1. Sakr Y, Reinhart K, Vincent JL, Sprung CL, Moreno R, Ranieri VM, De Backer D, Payen D. Does dopamine administration in shock influence outcome? Results of the Sepsis Occurrence in Acutely Ill Patients (SOAP) Study. Crit Care Med. 2006;34(3):589–597. doi: 10.1097/01.CCM.0000201896.45809.E3. - DOI - PubMed
1. Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, Jaeschke R, Mebazaa A, Pinsky MR, Teboul JL, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014;40(12):1795–1815. doi: 10.1007/s00134-014-3525-z. - DOI - PMC - PubMed
1. Vincent JL, De Backer D. Circulatory shock. N Engl J Med. 2013;369(18):1726–1734. doi: 10.1056/NEJMra1208943. - DOI - PubMed
1. Weil MH. Personal commentary on the diagnosis and treatment of circulatory shock states. Curr Opin Crit Care. 2004;10(4):246–249. doi: 10.1097/01.ccx.0000135265.30310.77. - DOI - PubMed
1. Hiemstra B, Eck RJ, Keus F, van der Horst ICC. Clinical examination for diagnosing circulatory shock. Curr Opin Crit Care. 2017;23(4):293–301. doi: 10.1097/MCC.0000000000000420. - DOI - PMC - PubMed

Grants and funding

LinkOut - more resources

Full Text Sources
Miscellaneous
- NCI CPTAC Assay Portal

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

Current use of vasopressors in septic shock

Affiliations

Current use of vasopressors in septic shock

Authors

Affiliations

Abstract

Figures

References

Grants and funding

LinkOut - more resources

Full Text Sources

Miscellaneous