Last-Line Vasopressors

Season #1 Episode #42

In this podcast episode, Dr. Terren Trott joins the host to discuss the critical topic of last-line vasopressors in septic shock. Dr. Trott emphasizes the challenges faced when standard approaches fail, leading to refractory septic shock in critically ill patients. He introduces four potential last-line interventions: angiotensin 2, IVIG (intravenous immunoglobulin), methylene blue, and esmolol. Dr. Trott reviews the rationale behind each intervention, citing studies and evidence to support their consideration. The discussion includes the risks associated with these last-line options and the importance of carefully assessing each patient's condition before implementing them. The key takeaway points include the potential benefits of angiotensin 2 in refractory shock, the controversial status of IVIG with weak recommendations against its use in sepsis guidelines, the promising role of methylene blue in inhibiting nitric oxide production, and the favorable outcomes seen with esmolol in reducing heart rate and mortality. Dr. Trott encourages a bedside approach, emphasizing the need for careful consideration and monitoring when exploring these last-line interventions in the critical care setting.

Takeaway Points:

  1. Angiotensin 2 shows promise as a last-line intervention in refractory septic shock, providing a potential multimodal approach to vasopressors.
  2. Intravenous immunoglobulin (IVIG) remains controversial, with conflicting evidence and a weak recommendation against its use in surviving sepsis guidelines.
  3. Methylene blue's inhibition of nitric oxide production presents a rational approach to improving vascular tone in septic shock, supported by positive outcomes in studies.
  4. Esmolol's short duration of action and benefits in reducing heart rate make it a viable option in septic shock, with studies demonstrating improved mortality and other positive outcomes.
  5. The bedside clinician is encouraged to judiciously explore these last-line interventions, considering the specific needs and responses of individual patients in the critical care setting.