Vasopressin in Conjunction With Norepinephrine in Septic Shock: A Retrospective Cohort Study From a Low Middle-Income Country

OBJECTIVES: Guidelines recommend use of norepinephrine as the first-line treatment for fluid-refractory septic shock and if septic shock persists vasopressin may be initiated. Since there are limited data from low middle-income countries with high disease burden of sepsis, we aimed to compare the outcomes of using vasopressin adjunct to norepinephrine in comparison with norepinephrine alone. DESIGN: Retrospective cohort study. SETTING: Aga Khan University Hospital, Karachi, Pakistan. PATIENTS: Six-hundred fifty-three patients diagnosed with septic shock from January 2019 to December 2019, with 498 given norepinephrine only and 155 given norepinephrine-vasopressin combination. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcome was in-hospital mortality. Secondary outcomes were duration of vasopressor used, length of hospital stay, length of ICU stay, and days on ventilatory support. After adjustment by multivariable logistic regression, it was found that mortality was not significantly associated with the norepinephrine-vasopressin combination (adjusted odds ratio, 0.633 [95% CI, 0.370–1.081]). However, Sequential Organ Failure Assessment score at admission (1.100 [1.014–1.193]), lactate at admission (1.167 [1.109–1.227]), duration of vasopressor used (1.481 [1.316–1.666]), and level of care (3.025 [1.682–5.441]) were found to be independently associated with the adjunct usage of norepinephrine and vasopressin. CONCLUSIONS: The use of norepinephrine-vasopressin combination has remained debatable in literature. Our study showed that although there was no difference in mortality between the two groups, admission Sequential Organ Failure Assessment scores and admission lactate levels were found to be significantly higher in the norepinephrine-vasopressin group. Hence, physicians from Pakistan used the norepinephrine-vasopressin combination in resistant septic shock patients who were sicker to begin with. Furthermore, duration of vasopressor therapy and ICU admission were also significantly higher in the combination group. Considering the recent hyperinflation of vasopressors costs and that most healthcare expenditure for patients in Pakistan is out-of-pocket, this can consequently lead to unwarranted financial burden for patients and their families.