Vasoplegia Treatments: The Past, the Present, and the Future

Bruno Levy; Caroline Fritz; Elsa Tahon; Audrey Jacquot; Thomas Auchet; Antoine Kimmoun

Disclosures

Crit Care. 2018;22(52) 

In This Article

Potential New Strategies

Very High Doses of Norepinephrine

Depending on the study, high doses of norepinephrine associated with excess mortality have been defined by a cut-off value ranging from 0.5 to 2 μg.kg−1.min−1, although converging evidence has recently confirmed the cut-off as 1 μg.kg− 1.min− 1.[30,62] Obviously, the level of MAP that is targeted should be taken into account.

Because these very high doses may be associated with potential deleterious effects, there is still controversy regarding increasing vasopressor dosage when conventional therapy fails to increase mean arterial pressure to the recommended target. The pharmacodynamic effects of catecholamines are characterized by a linear increase in effect, which is dependent on the logarithmic increase of the concentration, without any saturation at high doses.[63] Auchet et al.[62] found that a vasopressor dose higher than 0.75 μg.kg− 1.min− 1 was associated with a mortality of 86 % in patients with a SOFA score > 10 and with a mortality of 58 % in patients with a SOFA score < 10.

Moreover, the administration of high doses should be stopped in instances of serious adverse events. In two studies, myocardial, mesenteric, and digital ischemia occurred in less than 10 % of patients.[62,64] Moreover, adding an additional vasopressor (vasopressin) in order to reduce norepinephrine dosage was not associated with a lower incidence of serious adverse events.[64]

As a result, physicians should also consider an increase in norepinephrine dosage as a possible therapeutic option in instances of refractory hypotension associated with vasoplegia and adequate cardiac function, without the fear of ischemic complications.

processing....