Thread by @gretchemaben

Last for tweet-ucation in day 3 of #CHEST2021 - "Controversies in Septic Shock: Vasopressors and Corticosteroids"! #CHEST2021 1/

First up is Dr. Angel Coz Yataco will discuss "Adding Vasopressin Early" #CHEST2021 2/

Improved urine output and creatinine clearance with Vasopressin vs Levophed. #CHEST2021 3/

HR decreased and CI stable with Vasopressin compared to NE alone. #CHEST2021 4/

NE doses were reduced in patients who were also on Vasopressin. #CHEST2021 5/

Tachyarrhythmias were much higher with NE alone and skin ischemia was not different with or without Vasopressin. #CHEST2021 6/

This RCT randomized patients with septic shock to either Vasopressin + NE or NE alone. There was no difference in mortality at 28 or 90days. #CHEST2021 7/

The NE group was a little older. Also note that the MAPs at inclusion were in the low 70s, so these patients were actually not hypotensive when enrolled. #CHEST2021 8/

There was a mortality difference in patients with less severe shock and Vasopressin use. #CHEST2021 9/

In this trial more people needed RRT when on NE alone compared to Vasopressin. #CHEST2021 10/

In the VANISH trial there was more need for RRT in the NE alone group than those on Vasopressin. #CHEST2021 11/

In this meta-analysis digital ischemia was way more common in the catecholamine alone group, and there is potentially less mortality in the Vasopressin group. #CHEST2021 12/

This group also shows a possible decreased mortality in the Vasopressin group. #CHEST2021 13/

Conclusions #CHEST2021 14/

Dr. Stephen Pastores will speak on "Corticosteroids should be used in septic shock" #CHEST2021 15/

History of steroids in septic shock. #CHEST2021 16/

Biologic rationale for the use of corticosteroids #CHEST2021 17/

Side effects of steroids #CHEST2021 18/

The early use of short-term high dose steroids was previously found to be ineffective and harmful in septic shock. #CHEST2021 19/

Later studies showed that steroids may reverse the course of shock more quickly. JAMA trial that showed improved survival and reversal of septic shock in patients with relative adrenal insufficiency. The CORTICUS trial showed faster shock reversal. CHEST2021 20/

These guidelines suggest not using steroids in patients with sepsis without shock, but using HC in patients with septic shock that was unresponsive to moderate-to-high dose vasopressor therapy. #CHEST2021 21/

These trials came out in 2018 and studied patients with septic shock given HC (one also with Fludrocortisone). Both showed improved shock reversal with steroids. APROCCHSS also showed a mortality benefit. #CHEST2021 22/

This updated meta-analysis found a reduction in mortality, and shorter ICU/Hospital LOS, but increased risk of hypernatremia, hyperglycemia, and weakness. #CHEST2021 23/

This meta-analysis also supported reduced mortality. #CHEST2021 24/

Summary #CHEST2021 25/

Next up is Dr. Jonathan Sevransky (@jonsevransky) arguing "Corticosteroids do not make a difference" #CHEST2021 26/

Rationale for the use of steroids in septic shock. #CHEST2021 27/

The ADRENAL study showed no difference between the groups, but faster resolution of shock, and more adverse effects. #CHEST2021 28/

Updated meta-analyses have been done since ADRENAL and APPROCCHS and there MAY be a small effect on mortality. #CHEST2021 29/

Guidelines #CHEST2021 30/

One disclaimer is that we SHOULD use steroids in severe COVID. #CHEST2021 31/

Conclusions #CHEST2021 32/

And lastly Dr. Laura Evans (@Laura_Evans_206) will speak on "high dose Norepinephrine". #CHEST2021  33/

Pharmacology of NE #CHEST2021 34/

Guidelines for when to add Vasopressin and Epi. #CHEST2021 35/

This systematic review included 10 RCTs. There was a trend towards reduced mortality with Vasopressin. #CHEST2021 36/

This observational cohort showed that NE doses > 1 micrograms/kg/min had higher mortality than those who received less than that. #CHEST2021 37/

This study also showed higher mortality rates with NE >0.75 mic/kg/min. #CHEST2021 38/

Summary #CHEST2021 39/39