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Review
. 2022 May 30;12(1):47.
doi: 10.1186/s13613-022-01021-9.

Timing of vasoactive agents and corticosteroid initiation in septic shock

Mahmoud A Ammar  1 , Abdalla A Ammar  2 , Patrick M Wieruszewski  3 , Brittany D Bissell  4   5 , Micah T Long  6 , Lauren Albert  7 , Ashish K Khanna  8   9 , Gretchen L Sacha  10
Affiliations
Review

Timing of vasoactive agents and corticosteroid initiation in septic shock

Mahmoud A Ammar et al. Ann Intensive Care. .

Abstract

Septic shock remains a health care concern associated with significant morbidity and mortality. The Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock recommend early fluid resuscitation and antimicrobials. Beyond initial management, the guidelines do not provide clear recommendations on appropriate time to initiate vasoactive therapies and corticosteroids in patients who develop shock. This review summarizes the literature regarding time of initiation of these interventions. Clinical data regarding time of initiation of these therapies in relation to shock onset, sequence of treatments with regard to each other, and clinical markers evaluated to guide initiation are summarized. Early-high vasopressor initiation within first 6 h of shock onset is associated with lower mortality. Following norepinephrine initiation, the exact dose and timing of escalation to adjunctive vasopressor agents are not well elucidated in the literature. However, recent data indicate that timing may be an important factor in initiating vasopressors and adjunctive therapies, such as corticosteroids. Norepinephrine-equivalent dose and lactate concentration can aid in determining when to initiate vasopressin and angiotensin II in patients with septic shock. Future guidelines with clear recommendations on the time of initiation of septic shock therapies are warranted.

Keywords: Angiotensin II; Catecholamines; Corticosteroids; Resuscitation fluids; Sepsis; Septic shock; Vasoactive agents; Vasopressin.

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Conflict of interest statement

Dr. Khanna received grant support for the Angiotensin II in High Output Shock (ATHOS3) Trial and served as a consultant for the La Jolla pharmaceutical company and Edwards Lifesciences. He receives grant support from a Wake Forest Center for Hypertension and Cardiovascular Research award investigating the role of renin in septic shock and departmental support for an analysis of the role of renin in post cardiopulmonary bypass vasoplegia in patients receiving Angiotensin II. Dr. Wieruszewski has previously served on a scientific advisory board for the La Jolla pharmaceutical company. The rest of the authors declare no potential conflicts of interest concerning this article's research, authorship, and/or publication.

Figures

Fig. 1
Fig. 1
Identified gaps in the Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock (SSC) regarding initiation of vasoactive therapies and corticosteroids and suggested considerations for appropriate initiation of therapies
See this image and copyright information in PMC

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