In this episode, the hosts dive into the world of vasopressors, focusing on vasopressin and angiotensin-2 in trials like VASST, VANISH, and ATHOS-3. They discuss the challenges of managing blood pressure, trial outcomes, and implications for clinical practice. The chapter also explores ethical debates, treatment strategies, and the efficacy of different pressors in critical care settings.
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Quick takeaways
Vasopressin is commonly used as a second-pressor in sepsis management compared to angiotensin-2 due to accessibility.
Conducting a factorial study like the Vanish trial involves evaluating two interventions simultaneously with consistent criteria.
Challenges in patient enrollment for clinical trials highlight the importance of strategic trial design balancing feasibility and objectives.
Deep dives
Vasopressin Use in Sepsis Management
Vasopressin and angiotensin2 are discussed in relation to vasopressor use in sepsis management. The podcast delves into how these non-norepinephrine pressors are utilized, highlighting vasopressin as a common second-pressor in sepsis cases compared to angiotensin2, which may be less accessible in many institutions. The episode emphasizes listener feedback on blood pressure management, particularly focusing on the role of vasopressin in clinical practice.
Factorial Study Design in Vanish Trial
The discussion moves to the Vanish trial, characterized by a two-by-two factorial study design. This approach involves examining two interventions simultaneously, in this case, vasopressin versus norepinephrine and hydrocortisone versus placebo, within the same patient population. The podcast highlights the considerations and nuances of conducting a factorial study, emphasizing the need to ensure both questions have consistent inclusion and exclusion criteria.
Navigating Enrollment Challenges in Clinical Trials
The challenges of patient enrollment in clinical trials are highlighted, showcasing the complexities faced in recruiting patients early enough to meet study criteria. The podcast points out specific challenges with enrollment time frames, such as the six-hour window for vasopressor initiation, which led to a substantial number of exclusions in the Vanish trial. The need for strategic trial design to balance enrollment feasibility and study objectives is underscored throughout the episode.
Angiotensin 2 vs. Vasopressin in Shock Treatment
The discussion compares the use of angiotensin 2 and vasopressin as pressors in shock management. Angiotensin 2 showed an increase in mean arterial pressure compared to vasopressin, but the mortality outcomes did not statistically differ. The hyper-responder phenomenon with angiotensin 2, causing significant blood pressure elevations, prompts caution in certain populations due to its pro-thrombotic effects and potential risks. While angiotensin 2 may raise blood pressure effectively, predicting hyper-responders remains challenging, and its cost, thrombotic risk, and limited outcome improvement compared to vasopressin suggest a need for further research.
Clinical Considerations and Challenges with Angiotensin 2 Use
Angiotensin 2 therapy raises considerations in patient selection based on contraindications like pro-thrombotic risk and bronchospasm. Patient populations with heart failure or concerns for increased afterload require careful evaluation before initiating angiotensin 2 treatment. The lack of clear data on predicting hyper-responders and potential effects on mortality heighten the need for controlled studies. The discussion emphasizes the importance of individualizing therapy, considering outcomes beyond blood pressure elevation, and assessing risks in specific patient subgroups.
Episode 32! We got a lot of feedback on our last episode so we decided to address it in a full episode! A lot of listeners asked us about vasopressors specifically vasopressin and angiotensin-2 so we talk about VASST, VANISH, and ATHOS-3. It is a full episode but a good one!
If you enjoy the show be sure to like and subscribe, leave that 5 star review! Be sure to follow us on the social @icucast for the associated figures, comments, and other content not available in the audio format! Email us at icuedandtoddcast@gmail.com with any questions or suggestions! Thank you Mike Gannon for the intro and exit music!
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