Retrospective Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Jan 18, 2017; 9(2): 106-113
Published online Jan 18, 2017. doi: 10.4254/wjh.v9.i2.106
Vasopressin use in critically ill cirrhosis patients with catecholamine-resistant septic shock: The CVICU cohort
Lukasz A Myc, Jonathan G Stine, Rinita Chakrapani, Alexandra Kadl, Curtis K Argo
Lukasz A Myc, Department of Medicine, University of Virginia, Charlottesville, VA 22908, United States
Jonathan G Stine, Curtis K Argo, Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA 22908, United States
Rinita Chakrapani, School of Medicine, University of Virginia, Charlottesville, VA 22908, United States
Alexandra Kadl, Division of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, VA 22908, United States
Author contributions: Myc LA and Stine JG should be considered co-first authors of this manuscript as both made equally important contributions to the final manuscript; Myc LA and Argo CK generated the research concept and hypothesis; Myc LA, Stine JG and Argo CK designed research; Myc LA and Chakrapani R extracted data; Stine JG and Myc LA analyzed data; Myc LA, Stine JG, Chakrapani R, Kadl A and Argo CK composed the manuscript.
Institutional review board statement: Approval was obtained for this study from the University of Virginia IRB-HSR.
Informed consent statement: This study was retrospective and no informed consent was required by the IRB.
Conflict-of-interest statement: We have no conflicts of interest to report.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Curtis K Argo, MD, MS, Division of Gastroenterology and Hepatology, University of Virginia, JPA and Lee Street, MSB 2145, PO Box 800708, Charlottesville, VA 22908, United States. cka3d@virginia.edu
Telephone: +1-434-2432718 Fax: +1-434-9240491
Received: June 27, 2016
Peer-review started: June 30, 2016
First decision: August 26, 2016
Revised: September 23, 2016
Accepted: December 1, 2016
Article in press: December 2, 2016
Published online: January 18, 2017
Processing time: 203 Days and 0.8 Hours
Abstract
AIM

To examine patient-centered outcomes with vasopressin (AVP) use in patients with cirrhosis with catecholamine-refractory septic shock.

METHODS

We conducted a single center, retrospective cohort study enrolling adult patients with cirrhosis treated for catecholamine-resistant septic shock in the intensive care unit (ICU) from March 2011 through December 2013. Other etiologies of shock were excluded. Multivariable regression models were constructed for seven and 28-d mortality comparing AVP as a second-line therapy to a group of all other vasoactive agents.

RESULTS

Forty-five consecutive patients with cirrhosis were treated for catecholamine-resistant septic shock; 21 received AVP while the remaining 24 received another agent [phenylephrine (10), dopamine (6), norepinephrine (4), dobutamine (2), milrinone (2)]. In general, no significant differences in baseline demographics, etiology of cirrhosis, laboratory values, vital signs or ICU mortality/severity of illness scores were observed with the exception of higher MELD scores in the AVP group (32.4, 95%CI: 28.6-36.2 vs 27.1, 95%CI: 23.6-30.6, P = 0.041). No statistically significant difference was observed in unadjusted 7-d (52.4% AVP vs 58.3% and P = 0.408) or 28-d mortality (81.0% AVP vs 87.5% non-AVP, P = 0.371). Corticosteroid administration was associated with lower 28-d mortality (HR = 0.37, 95%CI: 0.16-0.86, P = 0.021) independent of AVP use.

CONCLUSION

AVP is similar in terms of patient centered outcomes of seven and 28-d mortality, in comparison to all other vasopressors when used as a second line vasoactive agent in catecholamine resistant septic shock. Large-scale prospective study would help to refine current consensus standards and provide further support to our findings.

Keywords: Portal hypertension; Vasopressor; Liver; Intensive care unit; Hepatology

Core tip: Although the management of septic shock has evolved dramatically in recent decades, data regarding optimal vasopressor therapy in critically-ill patients with cirrhosis is less robust and is based largely on consensus expert opinion. We found no difference in 7-d or 28-d mortality with vasopressin use when compared to all other vasoactive agents as a second line agent in catecholamine-resistant septic shock. Further large-scale studies are needed to refine current consensus standards and provide further support to our findings.