Dataset Information

Lower Versus Higher Exposure to Vasopressor Therapy in Vasodilatory Hypotension: A Systematic Review With Meta-Analysis.

ABSTRACT:

Objectives

Balancing the risks of hypotension and vasopressor-associated adverse effects is a daily challenge in ICUs. We conducted a systematic review with meta-analysis to examine the effect of lower versus higher exposure to vasopressor therapy on mortality among adult ICU patients with vasodilatory hypotension.

Data sources

We searched Ovid Medline, Embase, and the Cochrane Central Register of Controlled Trials for studies published from inception to October 15, 2021.

Study selection

We included randomized controlled trials of lower versus higher exposure to vasopressor therapy in adult ICU patients with vasodilatory hypotension without language or publication status limits.

Data extraction

The primary outcome was 90-day all-cause mortality, with seven prespecified subgroups. Secondary outcomes included shorter- and longer-term mortality, use of life-sustaining therapies, vasopressor-related complications, neurologic outcome, and quality of life at longest reported follow-up. We conducted random-effects meta-analyses to calculate summary effect measures across individual studies (risk ratio [RR] for dichotomous variables, mean difference for continuous variables, both with 95% CIs). The certainty of the evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluation. We registered this review on the International Prospective Register of Systematic Reviews (CRD42021224434).

Data synthesis

Of 3,403 records retrieved, 68 full-text articles were reviewed and three eligible studies included. Lower exposure to vasopressors probably lowers 90-day mortality but this is based on moderate-certainty evidence, lowered for imprecision (RR, 0.94; 95% CI, 0.87-1.02). There was no credible subgroup effect. Lower vasopressor exposure may also decrease the risk of supraventricular arrhythmia (odds ratio, 0.55; 95% CI, 0.36-0.86; low certainty).

Conclusions

In patients with vasodilatory hypotension who are started on vasopressors, moderate-certainty evidence from three randomized trials showed that lower vasopressor exposure probably lowers mortality. However, additional trial data are needed to reach an optimal information size to detect a clinically important 10% relative reduction in mortality with this approach.

SUBMITTER: Richards-Belle A

PROVIDER: S-EPMC9848218 | biostudies-literature | 2023 Feb

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Lower Versus Higher Exposure to Vasopressor Therapy in Vasodilatory Hypotension: A Systematic Review With Meta-Analysis.

Richards-Belle Alvin A Hylands Mathieu M Muttalib Fiona F Taran Shaurya S Rochwerg Bram B Day Andrew A Mouncey Paul R PR Radermacher Peter P Couban Rachel R Asfar Pierre P Adhikari Neill K J NKJ Lamontagne Francois F

Critical care medicine 20221118 2

<h4>Objectives</h4>Balancing the risks of hypotension and vasopressor-associated adverse effects is a daily challenge in ICUs. We conducted a systematic review with meta-analysis to examine the effect of lower versus higher exposure to vasopressor therapy on mortality among adult ICU patients with vasodilatory hypotension.<h4>Data sources</h4>We searched Ovid Medline, Embase, and the Cochrane Central Register of Controlled Trials for studies published from inception to October 15, 2021.<h4>Study ...[more]

PMID: 36398968

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Project description:BackgroundHigh dose vasopressors portend poor outcome in vasodilatory shock. We aimed to evaluate the impact of baseline vasopressor dose on outcomes in patients treated with angiotensin II (AT II).MethodsExploratory post-hoc analysis of the Angiotensin II for the Treatment of High-Output Shock (ATHOS-3) trial data. The ATHOS-3 trial randomized 321 patients with vasodilatory shock, who remained hypotensive (mean arterial pressure of 55-70 mmHg) despite receiving standard of care vasopressor support at a norepinephrine-equivalent dose (NED) > 0.2 µg/kg/min, to receive AT II or placebo, both in addition to standard of care vasopressors. Patients were grouped into low (≤ 0.25 µg/kg/min; n = 104) or high (> 0.25 µg/kg/min; n = 217) NED at the time of study drug initiation. The primary outcome was the difference in 28-day survival between the AT II and placebo subgroups in those with a baseline NED ≤ 0.25 µg/kg/min at the time of study drug initiation.ResultsOf 321 patients, the median baseline NED in the low-NED subgroup was similar in the AT II (n = 56) and placebo (n = 48) groups (median of each arm 0.21 µg/kg/min, p = 0.45). In the high-NED subgroup, the median baseline NEDs were also similar (0.47 µg/kg/min AT II group, n = 107 vs. 0.45 µg/kg/min placebo group, n = 110, p = 0.75). After adjusting for severity of illness, those randomized to AT II in the low-NED subgroup were half as likely to die at 28-days compared to placebo (HR 0.509; 95% CI 0.274-0.945, p = 0.03). No differences in 28-day survival between AT II and placebo groups were found in the high-NED subgroup (HR 0.933; 95% CI 0.644-1.350, p = 0.71). Serious adverse events were less frequent in the low-NED AT II subgroup compared to the placebo low-NED subgroup, though differences were not statistically significant, and were comparable in the high-NED subgroups.ConclusionsThis exploratory post-hoc analysis of phase 3 clinical trial data suggests a potential benefit of AT II introduction at lower doses of other vasopressor agents. These data may inform design of a prospective trial.Trial registrationThe ATHOS-3 trial was registered in the clinicaltrials.gov repository (no. NCT02338843). Registered 14 January 2015.

Project description:BackgroundSpinal anaesthesia is frequently used in surgical procedures involving the lower abdomen and extremities, however, the occurrence of hypotension remains a common and clinically important adverse effect. Unilateral spinal anaesthesia seems to be a promising approach to minimise this complication but the effectiveness of this remains controversial.ObjectiveA meta-analysis was undertaken to evaluate the superiority of unilateral spinal anaesthesia over bilateral spinal anaesthesia with regard to the incidence of hypotension and other complications.DesignSystematic reviews and meta-analysis of randomised controlled trials (RCTs).Date sourcesPUBMED, Embase, Web of Science and Cochrane Central Register of Controlled Trials databases were searched from their inception to 5 March 2024.Eligibility criteriaRandomised controlled trials (RCTs) comparing unilateral spinal anaesthesia with bilateral spinal anaesthesia were eligible for inclusion. Observational studies, case reports, case series, and studies not conducted in humans were excluded. The incidence of hypotension, vasopressor requirement, and other complications were compared. Heterogeneity was assessed by subgroup analyses and sensitivity analysis.ResultsTwenty-one trials involving 1358 patients undergoing unilateral lower extremity surgery or lower abdominal surgery were included in the meta-analysis. Hyperbaric solutions were used in most trials. The Mantel-Haenszel random-effect model was used for the analysis of binary endpoints, reported as relative risk (RR) with a 95% confidence interval (CI). The incidence of hypotension was significantly lower in the unilateral spinal anaesthesia group compared with the bilateral spinal anaesthesia (RR 0.38, 95% CI 0.27 to 0.55; P < 0.001; I2 = 38%). Subgroup analysis shows that the occurrence of hypotension was significantly lower in the unilateral subgroup, regardless of dosage, surgical site, adjuvants to the local anaesthetics, and different definitions of hypotension.ConclusionsUnilateral spinal anaesthesia is associated with a significant reduction in the occurrence of hypotension, despite variations in the definition of hypotension, adjuvants, and site of surgery. These results favour the use of lateral spinal anaesthesia in patients undergoing unilateral lower abdominal or lower limb surgery. However, the GRADE assessment of the quality of evidence was 'low' due to the high risk of bias and heterogeneity. All the results should be treated with caution.

Dataset Information

Lower Versus Higher Exposure to Vasopressor Therapy in Vasodilatory Hypotension: A Systematic Review With Meta-Analysis.

Objectives

Data sources

Study selection

Data extraction

Data synthesis

Conclusions

Publications

Lower Versus Higher Exposure to Vasopressor Therapy in Vasodilatory Hypotension: A Systematic Review With Meta-Analysis.

Similar Datasets

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