The pharmacotherapeutic options in patients with catecholamine-resistant vasodilatory shock

ABSTRACT

Introduction

Septic and vasoplegic shock are common types of vasodilatory shock (VS) with high mortality. After fluid resuscitation and the use of catecholamine-mediated vasopressors (CMV), vasopressin, angiotensin II, methylene blue (MB), and hydroxocobalamin can be added to maintain blood pressure.

Areas covered

VS treatment utilizes a phased approach with secondary vasopressors added to vasopressor agents to maintain an acceptable mean arterial pressure (MAP). This review covers additional vasopressors and adjunctive therapies used when fluid and catecholamine-mediated vasopressors fail to maintain target MAP.

Expert opinion

Evidence supporting additional vasopressor agents in catecholamine-resistant VS is limited to case reports, series, and a few randomized control trials (RCTs) to guide recommendations. Vasopressin is the most common agent added next when MAPs are not adequately supported with CMV. VS patients failing fluids and vasopressors with cardiomyopathy may have cardiotonic agents such as dobutamine or milrinone added before or after vasopressin. Angiotensin II, another class of vasopressor, is used in VS to maintain adequate MAP. MB and/or hydroxocobalamin, vitamin C, thiamine, and corticosteroids are adjunctive therapies used in refractory VS. More RCTs are needed to confirm the utility of these drugs, at what doses, which combinations and in what order they should be given.

KEYWORDS:

• Vasodilatory shock
• vasoplegic shock
• norepinephrine
• vasopressin
• angiotensin II
• methylene blue
• hydrocobalamin
• corticosteroids

Article highlights

• Vasodilatory or distributive shock is one of the most common mechanisms of shock

• Two types of vasodilatory shock include septic and vasoplegic shock

• After the source of shock is addressed, intravascular volume and electrolytes should be replaced

• Catecholamine-mediated vasopressors like norepinephrine are used to maintain mean arterial pressure (MAP)

• Argine vasopressin is added to norepinephrine if needed to maintain MAP and insure adequate organ perfusion

• Angiotensin II is added to norepinephrine and vasopressor to maintain adequate MAP

• Methylene blue and/or hydroxocobalamin are added to norepinephrine, vasopressin, and sometimes angiotensin II to maintain adequate MAP

• Inotropic agents and mechanical heart support are considered only in patients with low cardiac indexes/cardiomyopathy and low MAP despite vasopressor treatment

Declaration of interest

TE Albertson’s institution received research funding for the ATHOS-3 trial more than 5 years ago and he and CE Sandrock were paid consultant fees greater than 3 years ago from La Jolla Pharmaceutical. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.