Broad Spectrum Vasopressors

A New Approach to the Initial Management of Septic Shock?

Lakhmir S. Chawla; Marlies Ostermann; Lui Forni; George F. Tidmarsh

Disclosures

Crit Care. 2019;23(124) 

In This Article

Background

Sepsis remains the most common cause of vasodilatory shock worldwide. International consensus guidelines describe specific recommendations regarding treatment. These include the timing of important interventions comprising blood culture collection, initiation of broad-spectrum antibiotics, blood glucose targets, use of steroids, and restoration of optimal hemodynamic status.[1] The mainstay of treatment with regard to restoring and maintaining optimal hemodynamic status is rapid and appropriate fluid bolus therapy (FBT) which, if insufficient, is followed by vasopressor therapy to maintain an acceptable mean arterial pressure (MAP). Despite this approach being a cornerstone of therapeutic guidelines, there is a lack of high-quality evidence demonstrating a survival benefit associated with the use of one vasopressor over another.[2] Although current consensus guidelines recommend norepinephrine as the first-line vasopressor, both selection and timing of second-line therapy in refractory hypotension due to septic shock is highly variable. Indeed, in a recent survey of practice, only 14% of respondents cited a predefined dose of the first agent as the stimulus for additional therapy.[3,4] Selection of the vasopressor agent is also variable and further complicated by the recent data related to a "new" vasopressor, angiotensin II, which is currently only available in the USA.[5,6]

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