Vasopressin versus norepinephrine as the first-line vasopressor in septic shock: A systematic review and meta-analysis

Yub Raj Sedhai¹, Dhan Bahadur Shrestha^{2 *}, Pravash Budhathoki³, Waqas Memon⁴, Roshan Acharya⁵, Suman Gaire⁶, Nisheem Pokharel⁷, Swojay Maharjan⁸, Ranjit Jasaraj², Amik Sodhi⁹, Dipen Kadariya¹⁰, Ankush Asija¹¹, Markos G. Kashiouris¹²

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¹ Department of Internal Medicine, Division of Hospital Medicine, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, United States

² Department of Internal Medicine, Mount Sinai Hospital, Chicago, Illinois, United States

³ Department of Internal Medicine, Bronxcare Health System, Bronx, New York, United States

⁴ Department of Internal Medicine, Division of Nephrology, University of Virginia School of Medicine, Charlottesville, Virginia, United States

⁵ Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, North Carolina, United States

⁶ Department of Emergency Medicine, Palpa Hospital, Palpa, Nepal

⁷ Department of Emergency Medicine, KIST Medical College, Lalitpur, Nepal

⁸ Nepalese Army Institute of Health Sciences, Kathmandu, Nepal

⁹ Department of Internal Medicine, Division of Pulmonary Disease and Critical Care Medicine, University of Wisconsin, Madison, Wisconsin, United States

¹⁰ Attending Physician, Pulmonary Disease and Critical Care Medicine, Independent Practitioner

¹¹ Department of Internal Medicine, West Virginia University, Morgan Town, West Virginia, United States

¹² Department of Internal Medicine, Division of Pulmonary Disease and Critical Care Medicine, VCU School of Medicine, Richmond, Virginia, United States

JCTR 2022, 8(3), 185–199; https://doi.org/10.18053/jctres.08.202203.005

Submitted: 4 November 2021 | Revised: 21 March 2022 | Accepted: 30 March 2022 | Published: 25 May 2022

© 2022 by the Author(s). This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution -Noncommercial 4.0 International License (CC-by the license) ( https://creativecommons.org/licenses/by-nc/4.0/ )

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Abstract

Background and aim: Norepinephrine is currently the first-line vasopressor for septic shock. We conducted this meta-analysis to examine the outcomes of adult patients with septic shock who received vasopressin instead of norepinephrine.

Methods: We selected studies in adults with septic shock that compared the outcomes of patients treated with vasopressin versus norepinephrine. Cochrane ROB 2.0 and the JBI (Joanna Briggs Institute) quality assessment tools were used to assess the risk of bias in RCTs and observational studies. Meta-analysis was conducted using RevMan 5.4.

Results: Eight studies were included in this meta-analysis. There were no significant differences in 28-day mortality rates (OR, 1.07; CI, 0.80-1.44) and ICU mortality (OR, 0.74; CI, 0.21-2.67) between the two groups. Similarly, length of ICU stay, length of hospital stay, mean arterial pressure at 24 hours, urine output at 24 hours, and serious adverse events also did not differ significantly. However, the odds of renal replacement therapy (RRT) requirement in the vasopressin group were substantially lower than in the norepinephrine group (OR, 0.68; CI, 0.47-0.98).

Conclusion: There were no differences in mortality, duration of hospitalization, and adverse effects in adults with septic shock across the two groups. However, the patients treated with vasopressin had lower chances of requiring RRT.

Relevance for patients: Vasopressin use as the first-line vasopressor in septic shock showed a significant reduction in RRT though there were no significant differences in terms of mortality and other adverse events. Therefore, vasopressin can be considered as a first-line vasopressor in septic shock patients with other risk factors which may contribute to renal failure requiring RRT.

Keywords

norepinephrine

outcomes

renal replacement

septic shock

vasopressin

Conflict of interest

The authors declare that they have no competing interests.

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