Squeezing the Kidneys in Septic Shock

We have a bunch of gadgets and high-end drugs at our fingertips in ICU, but we seem to struggle with working out how best to use them. There is an endless search for which one is the best option, the first line magic bullet.

Acute kidney injury is a commonly reported marker of approaching badness for a patient being treated with an infection and septic shock. Strategies to maintain renal perfusion and avoid the need for renal replacement therapy (RRT) are regularly examined in the critical care literature. The latest trial to explore this theme is the VANISH Trial.

It examines the early (within 6 hours) use of either vasopressin or noradrenalin to limit the emergence of AKI and the need for RRT in a cohort (n=400) of sick adult patients (mean APACHE II = 24) with septic shock.

• Here’s the paper: The VANISH Trial (JAMA August 2, 2016, Vol 316, No. 5)
• Here’s a trial summary by Steve Mathieu on The Bottom Line: VANISH Trial
• Here’s a detailed analysis on PulmCrit.org by Josh Farkas: Renoresuscitation, vasopressin, vepinephrine, and VANISH (Includes links to previous trials on vasopressors and inotropes for septic shock, such as VASST)
• Here’s the lead author, Anthony Gordon, presenting the VANISH trial at Rob MacSweeney’s Critical Care Reviews Meeting: Vasopressin or Noradrenaline in Septic Shock – Should either VANISH

So, what am I going to do with this for my iatrogenically euvolaemic septic shock patient who has features implying the emergence of acute renal impairment?

Well, there may be a renal preservation role for vasopressin but it seems to be based purely on markers such as urine output and creatinine rise. The only reduction in the use of RRT was in septic shock non-survivors. Hmm!

1) I will probably lower my NorArd threshold for VP to 10-15ucg/min NorAdr +/- emerging AKI
2) I’d be more likely to use VP if vasodilatory shock dominant. Likely to avoid VP if sepsis-associated cardiogenic shock present due to afterload concerns.
3) Continue to regard Steroids as window dressing unless very elevated inflamatory markers or a history of prolonged steroid use (Again, this is probably less about whether a medication is beneficial and more about whether we understand how to use it. For more on this particular topic, listen to Jeremy Cohen’s Raging Hormones in the Critically Ill talk from SMACC Chicago).

What’ll you do?