What are the rates of recovery from concurrent administration of four vasopressors (vasoactive medications)?

From the Guidelines

Recovery from four vasopressors at one time requires careful weaning, starting with the most potent agent, typically epinephrine, followed by norepinephrine, then phenylephrine, and finally vasopressin, as recommended by the Surviving Sepsis Campaign guidelines 1. The weaning process should begin once hemodynamic stability is achieved, with a typical approach of reducing each medication by 10-20% of the current dose every 30-60 minutes while monitoring blood pressure, heart rate, and perfusion markers. Key considerations in this process include:

• Addressing the underlying cause of shock
• Maintaining adequate volume status
• Considering adjunctive therapies like corticosteroids for refractory shock
• The physiological basis for this approach is to gradually restore normal vascular tone while allowing the body's endogenous mechanisms to recover, preventing rebound hypotension from abrupt withdrawal of exogenous catecholamines. The guidelines suggest using norepinephrine as the first-choice vasopressor, with the option to add vasopressin or epinephrine to raise mean arterial pressure to target or decrease norepinephrine dosage 1. It is also recommended to avoid using low-dose dopamine for renal protection, as it has been shown to have no benefit in this context 1. Throughout the weaning process, it is crucial to closely monitor the patient's hemodynamic status and adjust the weaning schedule as needed to prevent instability. The use of an arterial catheter is suggested for patients requiring vasopressors, if resources are available, to facilitate close monitoring of blood pressure 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Rates of Recovery from Vasopressors

• The rates of recovery from vasopressors are not directly stated in the provided studies, but the efficacy and safety of different vasopressors are compared in various studies 2, 3, 4, 5, 6.
• A network meta-analysis study found that norepinephrine plus dobutamine is associated with a lower risk of 28-day mortality in septic shock patients than other vasoactive medications 4.
• Another study compared the efficacy and safety of norepinephrine plus dobutamine with those of epinephrine alone in septic shock, and found no significant difference in mortality rates between the two groups 5.
• The choice of vasopressor and dose varies widely due to patient and physician practice heterogeneity, and the adverse effects of vasopressors include excessive vasoconstriction, organ ischemia, hyperglycemia, hyperlactatemia, tachycardia, and tachyarrhythmias 2, 3.

Comparison of Vasopressors

• Norepinephrine is the first-choice vasopressor in septic and vasodilatory shock, and interventions that decrease norepinephrine dose (vasopressin, angiotensin II) have not decreased 28-day mortality significantly 2, 3.
• Epinephrine and vasopressin may be added in patients not responsive to norepinephrine, and angiotensin II may be useful for rapid resuscitation of profoundly hypotensive patients 2, 3.
• Dopamine has limited indications and is recommended only in bradycardic patients, while dobutamine may be added because vasopressors may decrease ventricular contractility 2, 3.

Future Directions

• Predictive biomarkers may guide vasopressor selection, and novel vasopressors may emerge with fewer adverse effects 2, 3.
• New strategies may include starting patients on several vasopressors with complementary mechanisms of action, and selecting patients for particular vasopressors according to predictive biomarkers 3.