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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com

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EMCrit Podcast 208 – Felipe Teran on Why We are Doing CPR Wrong

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martes, 16 de agosto de 2016

Renoresuscitation, vasopressin, vepinephrine, and VANISH

PulmCrit
PulmCrit - August 15, 2016 - By Josh Farkas 
"Introduction: Renoresuscitation
My goals during sepsis resuscitation focus largely on the preservation of renal function and maintenance of a reasonable fluid balance (renoresuscitation). The kidney is one of the most fragile organs, which may be rapidly injured by hypo perfusion. Renal failure correlates closely with mortality, participating in a vicious spiral of multi-organ failure. Alternatively, if you can save the kidneys, you’re likely to save the patient too.
In this context, any beneficial effect of vasopressin on renal function could be helpful. Vasopressin selectively constricts the afferent arteriole of the glomerulus, which should improve the glomerular filtration rate. Until last week, four RCTs had been performed comparing vasopressin vs. norepinephrine, each of which suggested that vasopressin improved renal function. However, the effect of vasopressin on renal function has never been investigated in a large RCT… until now.
  • Compared to norepinephrine, vasopressin caused a reduction in dialysis requirement. Patients in the vasopressin group also had lower creatinine levels and higher urine output.
  • There was no difference in the primary endpoint (days free of AKIN-3 renal failure). This could reflect imprecision in the AKIN-3 definition, which is a composite endpoint utilizing arbitrary cutoff values.
  • Vasopressin yielded equivalent mortality and complication rates compared to norepinephrine. This supports the use of vasopressin as a front-line vasopressor. It remains unclear which patients might benefit more from vasopressin vs. norepinephrine.
  • The conventional application of stress-dose steroids (i.e., for patients with vasopressor-refractory shock) had no impact on patient outcomes."