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Open Access Highly Accessed Research

Vasopressin and terlipressin in adult vasodilatory shock: a systematic review and meta-analysis of nine randomized controlled trials

Ary Serpa Neto1*, Antônio P Nassar2, Sérgio O Cardoso1, José A Manetta1, Victor GM Pereira1, Daniel C Espósito1, Maria CT Damasceno1 and James A Russell3

Author Affiliations

1 Medical Intensive Care Unit, ABC Medical School (FMABC), Lauro Gomes Avenue 1000, Santo André 09060-650, Brazil

2 Department of Intensive Care Medicine, São Camilo Hospital, Pompeia Avenue 1178, São Paulo 05024-000, Brazil

3 Heart and Lung Institute, Division of Critical Care Medicine, St Paul's Hospital, 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada

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Critical Care 2012, 16:R154  doi:10.1186/cc11469

Published: 14 August 2012

Abstract

Introduction

Catecholamines are the most used vasopressors in vasodilatory shock. However, the development of adrenergic hyposensitivity and the subsequent loss of catecholamine pressor activity necessitate the search for other options. Our aim was to evaluate the effects of vasopressin and its analog terlipressin compared with catecholamine infusion alone in vasodilatory shock.

Methods

A systematic review and meta-analysis of publications between 1966 and 2011 was performed. The Medline and CENTRAL databases were searched for studies on vasopressin and terlipressin in critically ill patients. The meta-analysis was limited to randomized controlled trials evaluating the use of vasopressin and/or terlipressin compared with catecholamine in adult patients with vasodilatory shock. The assessed outcomes were: overall survival, changes in the hemodynamic and biochemical variables, a decrease of catecholamine requirements, and adverse events.

Results

Nine trials covering 998 participants were included. A meta-analysis using a fixed-effect model showed a reduction in norepinephrine requirement among patients receiving terlipressin or vasopressin infusion compared with control (standardized mean difference, -1.58 (95% confidence interval, -1.73 to -1.44); P < 0.0001). Overall, vasopressin and terlipressin, as compared with norepinephrine, reduced mortality (relative risk (RR), 0.87 (0.77 to 0.99); P = 0.04). Vasopressin compared with norepinephrine decreased mortality in adult patients (RR, 0.87 (0.76 to 1.00); P = 0.05) and in patients with septic shock (42.5% vs. 49.2%, respectively; RR, 0.87 (0.75 to 1.00); P = 0.05; number needed to treat, 1 to 15). There was no difference in adverse events between the vasopressin and control groups (RR, 0.98 (0.65 to 1.47); P = 0.92).

Conclusions

Vasopressin use in vasodilatory shock is safe, associated with reduced mortality, and facilitates weaning of catecholamines. In patients with septic shock, use of vasopressin compared with norepinephrine may also decrease mortality.