Panelists to debate use of vasopressors and corticosteroids in septic shock

Clinicians have argued over the appropriate use of vasopressors and corticosteroids in septic shock for years. New evidence moves guidelines one way, then another, and practice patterns are everything except consistent, according to Angel Coz Yataco, MD, FCCP.

“Because of the variable trial data in corticosteroids in septic shock, a lot of practitioners have developed strong ideas, especially about using steroids in septic shock, or about how not to use them,” said Dr. Coz Yataco, who is a pulmonary and critical care specialist at the Cleveland Clinic Respiratory Institute. “It has become almost a religion—those who believe, use them, and those who do not believe, will not use them.”

Dr. Coz Yataco will chair a Clinical Controversy session, Controversies in Septic Shock: Vasopressors and Corticosteroids, on Tuesday at 4:00 pm CT. The panel will discuss the pros and cons of high-dose norepinephrine vs the utility of adding vasopressin earlier in therapy and will debate the use of corticosteroids.

Look for reaction, positive and negative, to the updated Surviving Sepsis Campaign guidelines, released earlier this month. The campaign suggests using corticosteroids in patients with septic shock with ongoing vasopressor requirements, based on the latest trial results. That contrasts with the prior recommendation, issued in 2016, to avoid corticosteroids in septic shock except in case of hypotension refractory to fluids and vasopressors.

The argument over vasopressors isn’t whether to use them in septic shock or not, but when and at what dose of norepinephrine should vasopressin be started. The Surviving Sepsis guidelines recommend norepinephrine as the first line vasopressor, which Dr. Coz Yataco noted is already the standard approach in non-resource limited environments such as the United States. The debate begins with what comes next.

It is clear that patients with profound shock need increasing doses of vasopressors, he continued. And while recent data suggest that adding vasopressin rather than increasing the dose of norepinephrine may be beneficial, there is a lot of variability in clinical practice, as many centers continue their existing practice of elevating norepinephrine toward the top end of the dosing range. Other centers have been adding vasopressin earlier, at lower doses of norepinephrine.

“There is some indirect data that vasopressin may have favorable outcomes regarding renal function and tachyarrhythmia,” Dr. Coz Yataco said. “And there are meta-analyses published in the last 2 to 3 years that show vasopressin could potentially improve mortality. But this has not been shown in a randomized controlled trial but inferred through data analysis. And there may be a benefit of adding vasopressin a bit earlier and not waiting until the doses of norepinephrine have gotten to be high.”

The trial data on corticosteroids are mixed and likely to stay that way until and unless there are randomized controlled trials showing strong results, he continued. But clinicians can benefit from understanding the latest literature, even if it is not definitive.

“It is also important to understand the newer literature in vasopressors,” Dr. Coz Yataco said. “It’s not randomized controlled trial data, it’s based on meta-analysis, but it’s sending some important signals that we ought to at least consider using vasopressin early. And that’s something that may not be happening as frequently as we would like. Septic shock is the most common killer in our ICUs, which makes these arguments very relevant to clinical practice. The audience can draw their own conclusions.”