Vasopressin use across shock states: international insights from an international ESICM-endorsed survey: the PRESS Survey
Javier Amador-Castañeda, BHS, RRT, FCCM, PNAP
| Respiratory Care Practitioner | Author | Speaker | Veteran | ESICM Representative, North America
Jozwiak, M., Cousin, V.L., De Backer, D. et al. Vasopressin use across shock states: international insights from an international ESICM-endorsed survey: the PRESS Survey. Crit Care 29, 273 (2025). https://doi.org/10.1186/s13054-025-05505-5
Summary
This international survey, endorsed by the European Society of Intensive Care Medicine (ESICM), assessed the current clinical use of vasopressin and terlipressin in patients with septic shock. The survey included 1,919 intensivists from 124 countries, highlighting significant variability in vasopressin availability, clinical indications, dosing strategies, and discontinuation practices. Results underscore the heterogeneity of current practices, suggesting an urgent need for clearer clinical guidelines and more personalized vasopressin use strategies in septic shock management.
Key Points
Survey Background and Rationale: Septic shock remains associated with significant morbidity and mortality, prompting international guidelines to recommend vasopressin as a second-line vasopressor. However, substantial uncertainty and variability in vasopressin use persist internationally.
Global Survey Participation: The survey received responses from 1,919 intensivists across 124 countries, predominantly from high and upper-middle income regions, providing broad international insights into vasopressin practices.
Clinical Indications for Vasopressin: Major indications reported included refractory septic shock (73% of respondents), catecholamine sparing in refractory shock (53%), refractory vasoplegic shock without left ventricular dysfunction (51%), and septic shock characterized by high cardiac output and low systemic vascular resistance (49%).
Contraindications and Risks: Common contraindications included non-occlusive mesenteric ischemia and digital or skin ischemia, with the most feared adverse effects being mesenteric ischemia, digital or skin ischemia, and cardiac ischemia.
Timing of Vasopressin Initiation: Vasopressin or terlipressin were predominantly initiated after initial fluid resuscitation and norepinephrine administration (93%), with initiation primarily triggered by doses of norepinephrine base between 0.25-0.50 µg/kg/min, typically after 2-6 hours of norepinephrine administration.
Dosage and Administration: Most respondents initiated vasopressin at fixed initial doses (0.01–0.03 U/min), commonly adjusting doses according to mean arterial pressure. Significant heterogeneity existed regarding initial dosing, titration approaches, and maximum dosages used.
Discontinuation Strategies: Discontinuation practices were varied, primarily guided by mean arterial pressure levels and reductions in norepinephrine dosage. Most respondents tapered vasopressin progressively once first-line vasopressor doses dropped below a predefined threshold.
Use of Corticosteroids: Corticosteroids were administered by 66% of respondents prior to considering second-line vasopressors, indicating variability in adherence to international guidelines recommending their use.
Role of Echocardiography: Echocardiography was the predominant hemodynamic monitoring tool employed (84%), reflecting broad acceptance of echocardiographic evaluation in critical care settings.
Practice Variability and Need for Guidance: Despite widespread use, significant variations exist globally regarding vasopressin handling. This variability highlights the need for clear and personalized clinical guidelines to optimize treatment outcomes.
Conclusion
This extensive international survey highlights substantial heterogeneity in the clinical use of vasopressin and terlipressin among intensivists managing septic shock, particularly concerning initiation triggers, dosing strategies, and discontinuation practices. It emphasizes the critical need for standardized guidelines and personalized approaches to improve clinical practice and patient outcomes.
Watch the following video on "Vasopressor Management in Septic Shock: General Overview and Personalized Approaches" by European Society of Intensive Care Medicine - ESICM
Discussion Questions
Given the heterogeneity in vasopressin initiation strategies observed globally, what practical recommendations could standardize practice without losing clinical flexibility?
How can real-time echocardiographic monitoring be systematically incorporated into personalized vasopressor management protocols for septic shock?
What further research or clinical trials are necessary to determine optimal dosing and timing of vasopressin initiation to enhance clinical outcomes in septic shock patients?
Javier Amador-Castañeda, BHS, RRT, FCCM, PNAP
Interprofessional Critical Care Network (ICCN)
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