A multicentre randomised trial to compare early use of vasopressin compared to norepinephrine to treat septic shock found no reduction in the number of kidney failure-free days compared with norepinephrine. The results of the VAsopressin vs. Noradrenaline as Initial therapy in Septic sHock (VANISH) trial are published in JAMA.
When asked to comment on the clinically important benefit for vasopressin which warranted further assessment, Dr. Gordon told ICU Management and Practice that the main outcome of this trial was a combination of survival and duration of kidney failure and there was no difference between treatment groups. However, there were improvements in some secondary outcomes related to kidney function, when patients received vasopressin. Most importantly less patients needed renal replacement therapy and they had greater urine output and lower creatinine levels over the first week in the vasopressin group. As the 95% confidence interval of the main outcome still includes a potential clinical benefit for vasopressin, larger trials would be required to test this.
Dr. Gordon also said that the results of the VANISH trial will probably not change routine first-line pressors for septic shock, i.e. norepinephrine. However, as less patients required renal replacement therapy (RRT) when treated early with vasopressin, then clinicians may consider starting vasopressin early in patients whose kidney function is deteriorating. This may reduce the later need for RRT which is important for patients. RRT requires additional catheters to be inserted into large veins in the neck or groin, and as well as being an additional bleeding and infection risk can reduce the patient’s opportunity to mobilize. Reducing RRT rates is also important for clinicians, as it is both labour intensive and costly.