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Vasopressors in septic shock: a systematic review and network meta-analysis.

Zhou F, Mao Z, Zeng X, Kang H, Liu H, Pan L, Hou PC - Ther Clin Risk Manag (2015)

Bottom Line: Compared to DA, NE was found to be associated with decreased cardiac adverse events, heart rate (standardized mean difference [SMD]: -2.10; 95% confidence interval [CI]: -3.95, -0.25; P=0.03), and cardiac index (SMD: -0.73; 95% CI: -1.14, -0.03; P=0.004) and increased systemic vascular resistance index (SVRI) (SMD: 1.03; 95% CI: 0.61, 1.45; P<0.0001).In terms of survival, NE may be superior to DA.When compared to DA, NE is associated with decreased heart rate, cardiac index, and cardiovascular adverse events, as well as increased SVRI.

View Article: PubMed Central - PubMed

Affiliation: Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China.

ABSTRACT

Objective: Vasopressor agents are often prescribed in septic shock. However, their effects remain controversial. We conducted a systematic review and Bayesian network meta-analysis to compare the effects among different types of vasopressor agents.

Data sources: We searched for relevant studies in PubMed, Embase, and the Cochrane Library databases from database inception until December 2014.

Study selection: Randomized controlled trials in adults with septic shock that evaluated different vasopressor agents were selected.

Data extraction: Two authors independently selected studies and extracted data on study characteristics, methods, and outcomes.

Data synthesis: Twenty-one trials (n=3,819) met inclusion criteria, which compared eleven vasopressor agents or vasopressor combinations (norepinephrine [NE], dopamine [DA], vasopressin [VP], epinephrine [EN], terlipressin [TP], phenylephrine [PE], TP+NE, TP + dobutamine [DB], NE+DB, NE+EN, and NE + dopexamine [DX]). Except for the superiority of NE over DA, the mortality of patients treated with any vasopressor agent or vasopressor combination was not significantly different. Compared to DA, NE was found to be associated with decreased cardiac adverse events, heart rate (standardized mean difference [SMD]: -2.10; 95% confidence interval [CI]: -3.95, -0.25; P=0.03), and cardiac index (SMD: -0.73; 95% CI: -1.14, -0.03; P=0.004) and increased systemic vascular resistance index (SVRI) (SMD: 1.03; 95% CI: 0.61, 1.45; P<0.0001). This Bayesian meta-analysis revealed a possible rank of probability of mortality among the eleven vasopressor agents or vasopressor combinations; from lowest to highest, they are NE+DB, EN, TP, NE+EN, TP+NE, VP, TP+DB, NE, PE, NE+DX, and DA.

Conclusion: In terms of survival, NE may be superior to DA. Otherwise, there is insufficient evidence to suggest that any other vasopressor agent or vasopressor combination is superior to another. When compared to DA, NE is associated with decreased heart rate, cardiac index, and cardiovascular adverse events, as well as increased SVRI. The effects of vasopressor agents or vasopressor combinations on mortality in patients with septic shock require further investigation.

No MeSH data available.


Related in: MedlinePlus

Ranking for mortality.Notes: Ranking indicates the probability to be the most mortality risk treatment, the second best, the third best, and so on, among the vasopressor agents.Abbreviations: DA, dopamine; DB, dobutamine; DX, dopexamine; EN, epinephrine; NE, norepinephrine; PE, phenylephrine; TP, terlipressin; VP, vasopressin.
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f4-tcrm-11-1047: Ranking for mortality.Notes: Ranking indicates the probability to be the most mortality risk treatment, the second best, the third best, and so on, among the vasopressor agents.Abbreviations: DA, dopamine; DB, dobutamine; DX, dopexamine; EN, epinephrine; NE, norepinephrine; PE, phenylephrine; TP, terlipressin; VP, vasopressin.

Mentions: Mortality in these 21 trials was 50.1% (1,915/3,819). When compared to NE, DA was associated with increased mortality (OR: 1.24, 95% CI: 1.01, 1.53). However, there was no significant difference in mortality in direct or indirect comparisons between other different vasopressor agents and vasopressor combinations (P>0.05) (Figure 3). For the probability of mortality, the possible rank from low to high was NE+DB (area under the curve [AUC]: 0.2648), EN (AUC: 0.3473), TP (AUC: 0.379), NE+EN (AUC: 0.3943), TP+NE (AUC: 0.3967), VP (AUC: 0.4212), TP+DB (AUC: 0.5423), NE (AUC: 0.5752), PE (AUC: 0.6796), NE+DX (AUC: 0.7279), and DA (AUC: 0.7718) (Figures 4 and 5). The tests of inconsistency for the two triangular closed loops were not significant (Figure 6). This meant that direct and indirect estimates had similar effects in the closed loop.15,17


Vasopressors in septic shock: a systematic review and network meta-analysis.

Zhou F, Mao Z, Zeng X, Kang H, Liu H, Pan L, Hou PC - Ther Clin Risk Manag (2015)

Ranking for mortality.Notes: Ranking indicates the probability to be the most mortality risk treatment, the second best, the third best, and so on, among the vasopressor agents.Abbreviations: DA, dopamine; DB, dobutamine; DX, dopexamine; EN, epinephrine; NE, norepinephrine; PE, phenylephrine; TP, terlipressin; VP, vasopressin.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4508075&req=5

f4-tcrm-11-1047: Ranking for mortality.Notes: Ranking indicates the probability to be the most mortality risk treatment, the second best, the third best, and so on, among the vasopressor agents.Abbreviations: DA, dopamine; DB, dobutamine; DX, dopexamine; EN, epinephrine; NE, norepinephrine; PE, phenylephrine; TP, terlipressin; VP, vasopressin.
Mentions: Mortality in these 21 trials was 50.1% (1,915/3,819). When compared to NE, DA was associated with increased mortality (OR: 1.24, 95% CI: 1.01, 1.53). However, there was no significant difference in mortality in direct or indirect comparisons between other different vasopressor agents and vasopressor combinations (P>0.05) (Figure 3). For the probability of mortality, the possible rank from low to high was NE+DB (area under the curve [AUC]: 0.2648), EN (AUC: 0.3473), TP (AUC: 0.379), NE+EN (AUC: 0.3943), TP+NE (AUC: 0.3967), VP (AUC: 0.4212), TP+DB (AUC: 0.5423), NE (AUC: 0.5752), PE (AUC: 0.6796), NE+DX (AUC: 0.7279), and DA (AUC: 0.7718) (Figures 4 and 5). The tests of inconsistency for the two triangular closed loops were not significant (Figure 6). This meant that direct and indirect estimates had similar effects in the closed loop.15,17

Bottom Line: Compared to DA, NE was found to be associated with decreased cardiac adverse events, heart rate (standardized mean difference [SMD]: -2.10; 95% confidence interval [CI]: -3.95, -0.25; P=0.03), and cardiac index (SMD: -0.73; 95% CI: -1.14, -0.03; P=0.004) and increased systemic vascular resistance index (SVRI) (SMD: 1.03; 95% CI: 0.61, 1.45; P<0.0001).In terms of survival, NE may be superior to DA.When compared to DA, NE is associated with decreased heart rate, cardiac index, and cardiovascular adverse events, as well as increased SVRI.

View Article: PubMed Central - PubMed

Affiliation: Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China.

ABSTRACT

Objective: Vasopressor agents are often prescribed in septic shock. However, their effects remain controversial. We conducted a systematic review and Bayesian network meta-analysis to compare the effects among different types of vasopressor agents.

Data sources: We searched for relevant studies in PubMed, Embase, and the Cochrane Library databases from database inception until December 2014.

Study selection: Randomized controlled trials in adults with septic shock that evaluated different vasopressor agents were selected.

Data extraction: Two authors independently selected studies and extracted data on study characteristics, methods, and outcomes.

Data synthesis: Twenty-one trials (n=3,819) met inclusion criteria, which compared eleven vasopressor agents or vasopressor combinations (norepinephrine [NE], dopamine [DA], vasopressin [VP], epinephrine [EN], terlipressin [TP], phenylephrine [PE], TP+NE, TP + dobutamine [DB], NE+DB, NE+EN, and NE + dopexamine [DX]). Except for the superiority of NE over DA, the mortality of patients treated with any vasopressor agent or vasopressor combination was not significantly different. Compared to DA, NE was found to be associated with decreased cardiac adverse events, heart rate (standardized mean difference [SMD]: -2.10; 95% confidence interval [CI]: -3.95, -0.25; P=0.03), and cardiac index (SMD: -0.73; 95% CI: -1.14, -0.03; P=0.004) and increased systemic vascular resistance index (SVRI) (SMD: 1.03; 95% CI: 0.61, 1.45; P<0.0001). This Bayesian meta-analysis revealed a possible rank of probability of mortality among the eleven vasopressor agents or vasopressor combinations; from lowest to highest, they are NE+DB, EN, TP, NE+EN, TP+NE, VP, TP+DB, NE, PE, NE+DX, and DA.

Conclusion: In terms of survival, NE may be superior to DA. Otherwise, there is insufficient evidence to suggest that any other vasopressor agent or vasopressor combination is superior to another. When compared to DA, NE is associated with decreased heart rate, cardiac index, and cardiovascular adverse events, as well as increased SVRI. The effects of vasopressor agents or vasopressor combinations on mortality in patients with septic shock require further investigation.

No MeSH data available.


Related in: MedlinePlus