Multimodal Vasopressor Strategy in Septic Shock

University Medical Centre Maribor79 enrolled

Overview

The goal of this prospective randomized controlled trial is to compare the effects of classic stepwise vs. early balanced multimodal vasopressor strategies in septic shock.

CONTROL GROUP(Classic stepwise vasopressor administration): Patients will be started on norepinephrine with increases of 0.05-0.1 mcg/kg/min up to 0.5 mcg/kg/min, followed by vasopressin (administered at a fixed dose of 0.03 IE/min). If MAP remains \< 65 mmHg, norepinephrine will be titrated above dose of 0.5 mcg/kg/min until MAP ≥ 65 mmHg. Initiation of additional vasoactive drugs (epinephrine, Ang II, methylene blue or dopamine) as per clinical team decision. Initiation of inotropes (dobutamine, milrinone, levosimendan) as per clinical team decision. EXPERIMENTAL GROUP(Balanced multimodal vasopressor administration): Early, simultaneous start of norepinephrine, angiotensin II and vasopressin at equivalent starting doses (equivalent to approximately 0.05 mcg/kg/min of norepinephrine). Increments of 0.05 mcg/kg/min of equivalent doses of all three vasopressors every 3-5 min until MAP ≥ 65 mmHg is reached (vasopressin will be administered at a maximum dose of 0.03 IE/min, Ang II will be administered at maximum dose of 100ng/kg/min). Initiation of additional vasoactive drugs (epinephrine, methylene blue or dopamine) as per clinical team decision. Initiation of inotropes (dobutamine, milrinone, levosimendan) as per clinical team decision.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

SINGLE

Enrollment

Conditions

Shock, Septic

Interventions

Simultaneous administration of vasopressorsOTHER

Early, simultaneous administration of norepinephrine, angiotensin II, and vasopressin.

Successive administration of vasopressorsOTHER

Administration and titration of norepinephrine and vasopressin. Administration of additional vasoactive drugs (epinephrine, methylene blue, angiotensin II or dopamine) as per clinical team. Initiation of inotropes (dobutamin, levosimendan, milrinone) as per clinical team decision.

Eligibility

Sex: ALLMin age: 18 Years

Medical Language ↔ Plain English

Inclusion Criteria: * Adult patients (≥18 years). * Sepsis (an acute change in total Sequential Organ Failure Assessment (SOFA) score ≥2 points consequent to infection) with persisting hypotension requiring vasopressors to maintain MAP ≥65 mm Hg and having a serum lactate level \>2 mmol/L despite adequate volume resuscitation (20-30ml/kg in 3 hours). * Vasopressor requirement of ≥0,15 μg/kg/min equivalent of norepinephrine base. * Patients are required to have central venous access and an arterial line present, and these are expected to remain present for at least the initial 72 hours of study. * Patients are required to have an urinary catheter present, and it is expected to remain present for at least the initial 72 hours of study. * Patients must have cardiac index (CI) \>2.3 L/min/m2 (measured by bedside echocardiography, pulse contour cardiac output (PiCCO) or Swan-Ganz catheter). Exclusion Criteria: * Death expected \<24 hours. * Pregnancy (suspected or confirmed). * Surgery expected for source of infection. * Inter-hospital transfer expected during first 72 hours of hospitalization. * Liver failure with a Model for End-Stage Liver Disease (MELD) score of ≥30. * Patients with acute mesenteric ischemia or a history of mesenteric ischemic. * Patients with Raynaud's phenomenon, systemic sclerosis or vasospastic disease. * Patients with active bleeding and an anticipated need (within 48 hours of initiation of the study) for transfusion of \>4 units of packed red blood cells. * Patients with a known allergy to mannitol. * Patients on veno-arterial (VA) ECMO.

Locations (2)

University Hospital Centre Zagreb

Zagreb, Croatia

Medical intensive care unit UMC Maribor

Maribor, Slovenia

Outcomes

Primary Outcomes

Rate of change in renin levels

There is an increasing amount of data that renin is the best marker of tissue hypoperfusion and predictor of ICU mortality in patients with sepsis and septic shock, even outperforming lactate. Renin increased between the first and third day in non-survivors, but dropped in survivors. The rate of change in renin concentration but not lactate concentration in ICU patients over first 72 hours is associated with in hospital mortality.

Time frame: 72 hours

Secondary Outcomes

Compare lactate levels

In critically ill patients, plasma lactate is commonly used to guide hemodynamic resuscitation. Hyperlactatemia has been widely recognized as a marker of tissue hypoxia/hypoperfusion but it can also result from increased or accelerated aerobic glycolysis during the stress response and may represent an important energy source in critically ill patients. Resuscitation to normalize lactate levels could worsen physiological status.

Time frame: 72h

Compare Δ Sequential Organ Failure Assessment (SOFA) score

The purpose is to monitor the rate of organ dysfunction. Score ranges from 0 (best) to 24 (worst) points.

Time frame: 72 hours

Compare acute kidney injury rate

The purpose is to monitor acute kidney injury based on Improving Global Outcomes (KDIGO) definition and staging system.

Time frame: 72 hours

Data from ClinicalTrials.gov

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