Vasoactive drugs for vasodilatory shock in ICU

Vasoactive drugs are the mainstay of hemodynamic management of vasodilatory shock when fluids fail to restore adequate tissue perfusion. In this review, studies published during the past year that increase our understanding of the use of vasoactive drugs in the ICU are discussed.

The Vasopressin and Septic Shock Trial did not find a difference between low-dose vasopressin and norepinephrine vs. norepinephrine alone in the hemodynamic support of septic shock, suggesting that either approach is reasonable. However, vasopressin may be beneficial in the less severe septic shock subgroup. In this study, patients who were also treated with corticosteroids, vasopressin, compared with norepinephrine, were associated with significantly decreased mortality. Epinephrine, phenylephrine and terlipressin can be used safely in the ICU setting as first-line therapy for septic shock. The incidence of global left ventricular hypokinesia in patients with septic shock is 60%, much higher than previously described. Although dobutamine remains the gold standard therapy for septic myocardial depression, combined milrinone and metoprolol therapy may be an effective alternative therapy.

Current evidence does not support a clear recommendation of one vasopressor over another; indeed norepinephrine, vasopressin, terlipressin, phenylephrine and epinephrine may be used safely with similar survival outcomes.