Shock, Septic
Conditions
Brief summary
The goal of this observational study is to learn about blood pressure response to the vasopressor drug vasopressin in people with septic shock. The main questions it aims to answer are: * Are the levels of molecules showing communication between cells different between people whose blood pressure improves and people whose blood pressure does not improve when given a vasopressor medication? * Are measurements found on echocardiography (heart ultrasound) different between people whose blood pressure improves and people whose blood pressure does not improve when given a vasopressor medication? * Are measurements of blood oxygen in tissues just below the skin different between people whose blood pressure improves and people whose blood pressure does not improve when given a vasopressor medication? Participants will be asked to contribute one or two blood samples. Participants who are ordered the drug vasopressin will contribute two blood samples. Both samples will be about two tablespoons for a total of about four tablespoons. One sample will be drawn before starting vasopressin infusion and the second sample will be drawn between one and six hours after starting the vasopressor drug infusion. At the same time points, advanced echocardiography pictures and measurements of oxygen in tissues from a sensor placed on one of the hands will be taken. Participants who are not ordered the drug vasopressin and only ordered the drug norepinephrine will contribute only one blood sample. At the time the sample is collected, advanced echocardiography pictures and measurements of oxygen in tissues from a sensor placed on one of the hands will be taken. This research also involves analyzing data obtained during the participant's hospital stay.
Detailed description
Septic shock mortality remains high at 33% in North America; current clinical predictors of poor outcomes in septic shock are suboptimal. In addition to antibiotics and intravenous fluids, vasoactive agents are initiated to restore effective tissue perfusion. Norepinephrine (NE) is the recommended first-line vasopressor, but adjunctive arginine vasopressin is used in over one-third of patients to improve blood pressure or decrease NE dosage. However, less than half of vasopressin recipients have a clinically-apparent hemodynamic response (defined as a decrease in NE dosage at 6 hours after vasopressin initiation). Vasopressors, particularly norepinephrine, are known to be immune modulators. Further, each vasopressor has its own unique effect on a patient's hemodynamic profile as assessed by echocardiography and microcirculation measurements. In the current study, the investigators seek to clarify the link between vasopressin, immune response, hemodynamic profile, and microcirculatory measurments. The central goal of this proposal is to identify "vasopressin response" as an easily-identifiable bedside indicator of a distinct septic shock subphenotype.
Interventions
DRUGVasopressin
Fixed dosage vasopressin ordered as an adjunctive vasopressor to norepinephrine
Sponsors
The Cleveland Clinic
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Adult patients (≥18 years old) * Septic shock (as defined by Sepsis-3) * Receiving norepinephrine * Admitted to a medical, surgical, NeuroSciences, or mixed intensive care unit * Central venous catheter in place * Ordered fixed-dose vasopressin as an adjunct to norepinephrine by the primary care team (unless in active control cohort)
Exclusion criteria
* Vasopressin ordered for an indication other than septic shock * Vasopressin initiated at another institution * Receiving a primary vasopressor other than norepinephrine (eg, phenylephrine) * Positive test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within the preceding 28 days * Blood hemoglobin concentration \<7 g/dL * Primary treatment team determines that vasopressin initiation is emergent * Patient or their legal authorized representative opts to not participate in the study
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Ratio of plasma interleukin-10 (IL-10) to tumor necrosis factor-α (TNF-α) | Baseline (before vasopressin initiation and within 45 minutes of order placement). | Compare baseline ratio of plasma concentrations of interleukin-10 (IL-10) to tumor necrosis factor-α (TNF-α) in vasopressin responders vs. non-responders. The active control cohort of patients who are only receiving norepinephrine will serve as a control for this analysis. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Left ventricular ejection fraction (LVEF) | Baseline (before vasopressin initiation and within 45 minutes of order placement). | Compare baseline left ventricular ejection fraction (LVEF) in vasopressin responders vs. non-responders. The active control cohort of patients who are only receiving norepinephrine will serve as a control for this analysis. |
| Ratio of ratio of arterial elastance (Ea) to left ventricular end-systolic elastance (Ees) | Baseline (before vasopressin initiation and within 45 minutes of order placement) through one to six hours after vasopressin initiation. | Compare left ventricular-arterial coupling (ratio of arterial elastance \[Ea\] to left ventricular end-systolic elastance \[Ees\]) over time in vasopressin responders vs. non-responders. The active control cohort of patients who are only receiving norepinephrine will serve as a control for this analysis. |
| Lipopolysaccharide-stimulated monocyte TNF-α secretion | Baseline (before vasopressin initiation and within 45 minutes of order placement) through one to six hours after vasopressin initiation. | Compare lipopolysaccharide-stimulated monocyte TNF-α secretion over time in vasopressin responders vs. non-responders. The active control cohort of patients who are only receiving norepinephrine will serve as a control for this analysis. |
| Monocyte adhesion | Baseline (before vasopressin initiation and within 45 minutes of order placement) through one to six hours after vasopressin initiation. | Compare monocyte adhesion over time in vasopressin responders vs. non-responders. The active control cohort of patients who are only receiving norepinephrine will serve as a control for this analysis. |
| Plasma renin concentration | Baseline (before vasopressin initiation and within 45 minutes of order placement) through one to six hours after vasopressin initiation. | Compare plasma renin concentration over time in vasopressin responders vs. non-responders. The active control cohort of patients who are only receiving norepinephrine will serve as a control for this analysis. |
| Plasma angiopoietin-2 concentration | Baseline (before vasopressin initiation and within 45 minutes of order placement) through one to six hours after vasopressin initiation. | Compare plasma angiopoietin-2 concentration over time in vasopressin responders vs. non-responders. The active control cohort of patients who are only receiving norepinephrine will serve as a control for this analysis. |
| StO2 recovery slope (%/min) | Baseline (before vasopressin initiation and within 45 minutes of order placement) through one to six hours after vasopressin initiation. | Compare tissue oxygenation (StO2) recovery slope, during the reperfusion phase of a vascular occlusion test (VOT), over time between vasopressin responders vs non-responders. The active control cohort of patients who are only receiving norepinephrine will serve as a control for this analysis. |
| Difference in StO2 (%) | Baseline (before vasopressin initiation and within 45 minutes of order placement) through one to six hours after vasopressin initiation. | Compare the difference between maximum tissue oxygenation (StO2) and minimum StO2, during the reperfusion phase of a vascular occlusion test (VOT), over time between vasopressin responders vs non-responders. The active control cohort of patients who are only receiving norepinephrine will serve as a control for this analysis. |
Countries
United States
Contacts
PRINCIPAL_INVESTIGATORSeth Bauer, PharmD
The Cleveland Clinic
Outcome results
None listed