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This review supports current guidance that noradrenaline should be used as the rst-choice
vasopressor for adults with septic shock. Noradrenaline reduced mortality (Death.) by 11% and
major adverse events by two-thirds compared to dopamine. However, evidence of its effectiveness
compared to the other vasopressors remains limited. Septic shock accounts for nearly one in ten
admissions to intensive care units, where it is the most common cause of death. The survival rate
for septic shock is only about 50%.
Vasopressors are drugs that cause blood vessels to narrow, thereby increasing blood pressure and
hence the ow of blood. They are used to treat patients with septic shock, helping to restore blood ow
to the vital organs and the rest of the body.
No single study had previously demonstrated survival benet of one vasopressor over another.
Therefore this reviews objective was to assess the overall evidence for the efciency and safety of all
vasopressors for septic shock.
Standard systematic review (This is a synthesis of the medical research on a particular subject. It uses
tho...) methods were used. Many of the trials were very small, just ve trials included over a hundred
patients. Trial quality was variable and differed with regard to dosages, timings and outcomes measure.
However, the authors were careful to take into account the variety of trials in their analyses and so the
results should be reliable.
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NICE are in the process of developing guidance in this area. The expected publication date is July
2016. The scope document states that the NICE guidance will not replicate the existing Surviving
Sepsis Campaign guidelines.
More trials are needed. The authors recommend that future trials should use a common sepsis
management protocol (including the use of uid resuscitation and steroids) and report not only all-
cause mortality (Death.) but also length of hospital stay, length of ventilation, length of vasopressor
support and adverse events.
Citation
Avni T, Lador A, Lev S, et al. Vasopressors for the treatment of septic shock: Systematic review (This is
a synthesis of the medical research on a particular subject. It uses tho...) and meta-analysis (This is a
mathematical technique that combines the results of individual studies...)
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4523170/). PLoS One. 2015; 10(8): e0129305.
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Bibliography
Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign Guidelines Committee including
the Pediatric Subgroup. Surviving sepsis campaign: international guidelines for management of severe
sepsis and septic shock: 2012 (http://www.sccm.org/Documents/SSC-Guidelines.pdf). Crit Care Med.
2013; 41(2): 580-637.
Martin GS. Sepsis, severe sepsis and septic shock: changes in incidence, pathogens and outcomes
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3488423/). Expert Rev Anti Infect Ther. 2012;10(6):701-
6
NICE. Sepsis: the recognition, diagnosis and management of severe sepsis. Final scope
(https://www.nice.org.uk/guidance/gid-cgwave0686/resources/sepsis-the-recognition-diagnosis-and-
management-of-severe-sepsis-nal-scope2). London: National Institute for Health and Care
Excellence, 2014.
Expert commentary
The important nding of this study is that noradrenaline is superior to dopamine but non-superior to
other therapeutic strategies including dual vasopressors. This supports what is already usual practice
in the UK. It adds to the weight of evidence supporting noradrenaline as the vasopressor of choice in
septic shock, which represents the biggest proportion of cases of severe sepsis. Evidence is currently
being reviewed by NICE and this and other evidence will be considered by the Surviving Sepsis
Campaign in their revised guidelines next year. It is hoped that this and similar works will help us to
reach international consensus in a critical aspect of the management of these complex cases.
Dr Ron Daniels, CEO of UK Sepsis Trust and Global Sepsis Alliance, Clinical Adviser to NHS
England
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