Effect of norepinephrine versus vasopressin weaning on incidence of hypotension in septic shock patients: a systematic review and meta-analysis

Abstract

Objective: To evaluate the influence of weaning vasopressors – norepinephrine or vasopressin-on deleterious effects; the main objective was to evaluate the incidence of hypotension. Methods: We performed a systematic review and meta-analysis of 11 studies-2 randomized controlled trials and 9 observational studies-involving 2,280 patients in whom norepinephrine (n = 1,254) or vasopressin (n = 1,026) was withdrawn first to compare the risk of hypotension and other adverse effects. Results: Hypotension occurred in 33.4% (420/1,254) of patients in the Norepinephrine Group and in 52,4% (538/1,026) of patients in the Vasopressin Group. There was no difference between groups regarding the incidence of hypotension: OR 0.43 (95%CI 0.18-1.03). The subgroup analysis of observational studies suggests a lower incidence of hypotension when norepinephrine is weaned first (OR 0.26; 95%CI 0.13-0.53), with high heterogeneity between studies (I2 = 88%; p < 0.01). On the other hand, the subgroup of randomized controlled trials indicates a higher incidence of hypotension when norepinephrine is weaned first (OR 4.04; 95%CI 1.24-13.15; I2 = 65%, p = 0.09). The weaning strategy was not associated with other outcomes, including intensive care unit length of stay, hospital length of stay, time on vasopressors, arrhythmias, renal injury, or SOFA. Conclusion: No differences in hypotension incidence were observed when weaning was initiated with either norepinephrine or vasopressin. However, the high heterogeneity observed across studies warrants caution in drawing definitive conclusions.