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The following is a summary of “Non-adrenergic vasopressors for vasodilatory shock or perioperative vasoplegia: a meta-analysis of randomized controlled trials,” published in the December 2024 issue of Critical Care by Kotani et al.
Concerns exist regarding potential harm from excessive adrenergic vasopressor use, prompting exploration of non-adrenergic alternatives that may spare adrenergic agents and potentially improve patient outcomes.
Researchers conducted a retrospective study to evaluate the efficacy of non-adrenergic vasopressors in adults undergoing vasopressor therapy for vasodilatory shock or perioperative vasoplegia.
They reviewed randomized controlled trials (RCTs) from PubMed, Embase, and Cochrane Library, comparing non-adrenergic vasopressors with adrenergic vasopressors or placebo in individuals with critical illness or perioperative. Eligible studies were grouped into septic shock, cardiac surgery, or non-cardiac surgery categories. Non-adrenergic vasopressors analyzed included vasopressin, terlipressin, selepressin, angiotensin II, methylene blue, and hydroxocobalamin. The primary outcome was mortality at the longest follow-up. A random-effects meta-analysis was performed, and the study protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (CRD42024505039).
The results showed 51 eligible RCTs were included with 5,715 participants, with the majority from septic shock (30 studies), cardiac surgery (11 studies), and non-cardiac surgery (10 studies). The Cochrane risk-of-bias tool identified 17 studies as low risk. In septic shock, mortality was lower in the non-adrenergic group (960/2232 [43%] vs 898/1890 [48%]; risk ratio [RR], 0.92; 95% CI, 0.86–0.97; P = 0.03; I2 = 0%). No significant survival benefits were seen for individual non-adrenergic vasopressors. No mortality difference was found in cardiac surgery (34/410 [8.3%] vs 47/412 [11%]; RR, 0.82; 95% CI, 0.55–1.22; P = 0.32; I2 = 12%) or non-cardiac surgery (9/388 [2.3%] vs 18/383 [4.7%]; RR, 0.66; 95% CI, 0.31–1.41; P = 0.28; I2= 0%).
Investigators concluded that while non-adrenergic vasopressors demonstrated potential for reduced mortality in septic shock and a possible benefit in patients with surgery, further RCTs are warranted to definitively establish their clinical efficacy.
Source: ccforum.biomedcentral.com/articles/10.1186/s13054-024-05212-7
