Vasopressin use across shock states: international insights from an international ESICM-endorsed survey: the PRESS Survey.

backgroundVasopressin is currently suggested as a second-line vasopressor in patients with septic shock and persistent arterial hypotension. This survey aimed to assess the current use of vasopressin and terlipressin in patients with septic shock.

methodsAn international survey endorsed by the European Society of the Intensive Care Medicine. All items addressed the different areas of uncertainty and research identified from current international recommendations. 

results1919 intensivists from 124 countries responded to the survey: 1220(64%) worked in Europe, 1430(74%) in high and upper-middle income level countries and 916(48%) in academic ICUs. Vasopressin or terlipressin were available to 1830(95%) respondents. The main reported indications were refractory septic shock, catecholamine sparing in all types of refractory shock, refractory vasoplegic shock (other than septic) without reduced left ventricular systolic function and septic shock with high cardiac output and low systemic vascular resistance (73%,53%,51% and 49% of respondents, respectively). The main reported contraindications were non-occlusive mesenteric ischemia and digital or skin ischemia. Overall, 1506(78%) respondents used vasopressin or terlipressin, 93% of them as a second-line vasopressor after initial resuscitation, mainly to increase blood pressure and reduce the catecholamine load. The dose of norepinephrine alone or the duration of norepinephrine administration alone triggered vasopressin and terlipressin initiation for 98% and 53% of respondents, respectively: the most frequent dose of norepinephrine base was 0.25-0.50 µg/kg/min and the most frequent duration was > 2-6 h. The combination of the dose of norepinephrine base and the duration of its administration triggered vasopressin and terlipressin initiation for 78% of respondents, the most frequent combination being a norepinephrine base dose > 0.25 or > 0.50 µg/kg/min for > 2-6 h. An initial dose of vasopressin of 0.01 or 0.03 U/min was used by 50% of respondents. The mean arterial pressure level triggered the tapering of vasopressin or terlipressin for 88% of respondents. Discontinuation started after the dose of the first-line vasopressor had been lowered below a predefined threshold for 43% of respondents and was progressive for 89% of respondents.

conclusionsVasopressin is commonly used to treat patients with septic shock, but its handling (doses and discontinuation practices) remains heterogeneous, indicating the need for guidance in its clinical use.