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Hemodynamics Management

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Timing of Vasopressin Addition to Norepinephrine and Efficacy Outcomes in Patients With Septic Shock


This retrospective study is aimed to determine whether the timing of adding vasopressin to norepinephrine affects the resolution of shock in patients with septic shock. The study analyzed a total of 243 patients and divided them into two groups: early vasopressin addition (<3 hours) and late vasopressin addition (≥3 hours). The primary outcome measured was the time to shock resolution, defined as being free from vasopressors for at least 24 hours. The study found that the early addition of vasopressin resulted in a statistically significant decrease in the time to shock resolution compared to the late addition group. The early addition of vasopressin did not affect norepinephrine dose or in-hospital mortality but did lead to a decreased length of stay in the intensive care unit (ICU).


When do you add vasopressin to norepinephrine (levophed) in patients with septic shock?

  • Within 3 hrs if levophed is escalating regardless of dose

  • When dose of levophed dose reaches 0.2-0.25 mcg/kg/min

  • When evophed dose increases above 0.25-0.3 mcg.kg/min


Perspective: This study contributes to the existing knowledge on the timing of vasopressin addition in septic shock. Current guidelines recommend adding vasopressin if the target mean arterial pressure (MAP) is not achieved with norepinephrine. However, the optimal timing for initiating vasopressin remains unclear. This study suggests that early initiation of vasopressin within 3 hours of starting norepinephrine may lead to faster resolution of shock in patients with septic shock. It is important to note that the study did not account for potential confounding factors such as the frequency of vitamin C administration and fluid dose prior to starting norepinephrine. Further research is needed to confirm these findings and explore the impact of other interventions on the outcomes of septic shock patients.


Brask AL, Shemanski SM, Barnes TE, Holmes AK. Timing of Vasopressin Addition to Norepinephrine and Efficacy Outcomes in Patients With Septic Shock. Ann Pharmacother. 2023 May;57(5):521-526. doi: 10.1177/10600280221118903. Epub 2022 Aug 29. Erratum in: Ann Pharmacother. 2023 Jan 5;:10600280231151309. PMID: 36039490. Link

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