Non-catecholaminergic vasopressors in the management of shock: a narrative review and meta-analysis of randomized clinical trials

Abstract

Refractoriness to catecholamines is a final potential hemodynamic
state for all types of circulatory shock leading to the administration of
high doses of catecholamines, which is associated with poor clinical
outcomes. The pathophysiology of systemic vasodilation is complex,
in this sense, there is a rising interest in non-catecholaminergic
vasopressors which target different vasoconstriction pathways,
potentially resulting in a synergistic vasopressor effect.
The purpose is to assess the hemodynamic and clinical response
of patients with shock associated with sepsis, post cardiac surgery
(POCC) and burns to non-catecholaminergic vasopressors.
PubMed, LILACS, Embase and the Cochrane Central Register were
searched. Clinical studies and reviews in adult patients with septic,
postcardiac surgery and burns shock with the administration of at
least one of the following non adrenergic vasopressors: methylene
blue (MB), angiotensin II (AII), vasopressin (VP), terlipressin (TP) were
included. A literature review and a meta-analysis of randomized
clinical trials was done to analyze hemodynamic variables,
catecholaminergic sparing effect and mortality.

137 articles were included, 31 clinical trials for the metanalysis. The
qualitative revision showed an increase in mean arterial pressure
(MAP), systemic vascular resistance (SVR) and a catecholamine
sparing effect for all vasopressors. Metanalysis results evidenced a
significant decrease in mortality in shock postcardiac surgery with
MB (RR: 0,12 IC95%: 0,02;0,95). Non-significant effects were shown for
mortality in septic shock.
All included vasopressors increase MAP resulting in a
catecholamine sparing effect with no decrease in cardiac output.
Effects on mortality are less precise.