What is the evidence around various pressors in COVID-19-related hypotension?

Posted on April 7, 2020 by Raymond Cho

Summary

Norepinephrine is used as first line treatment (epinephrine and vasopressin as first line if norepinephrine is not available). Vasopressin should be added as a second-line agent if MAP target of 65 mmHg is not reached. Dopamine should not be used due to risk of arrhythmia.

I.   INDICATIONS FOR VASOPRESSORS IN COVID-19-RELATED SHOCK

  • Myocardial infarction, myocarditis, sepsis, pulmonary embolism, pulmonary hypertension due to excessive ventilation have been reported as causes of shock in COVID-19 (1).
  • The cause of death from COVID-19 is often ARDS, which can be exacerbated by administering excessive fluids. Therefore, the WHO recommends that small, rapid boluses of crystalloid fluid (250-500 mL) should be given to allow for reassessment of volume status following each bolus. If there is no response to fluid loading or signs of volume overload appear (JVD, crackles or pulmonary edema), fluid administration should be discontinued (2).
  • Vasopressors are indicated in patients in whom shock persists after fluid resuscitation, cannot maintain a MAP ≥ 65 AND lactate ≥ 2 mmol/L (2).
  • Case reports and small studies report using vasopressors in 35-71% of patients who experienced shock  secondary to COVID-19 (3, 4, 5).

II.   VASOPRESSORS USED IN COVID-19-RELATED VASODILATORY SHOCK

  • There are a lack of studies comparing the efficacy of different vasopressors in COVID-19-related vasodilatory shock. Most recommendations from WHO and the Surviving Sepsis Campaign on hemodynamic support are from general critically ill patients (2,6).
  • A Cochrane review on vasopressors for hypotensive shock (non-COVID-19-related) compared 6 different vasopressors (norepinephrine, epinephrine, dopamine, terlipressin, vasopressin, phenylephrine) across 28 RCTs (3497 patients) with outcomes measures in mortality, length of stay in hospital and occurrence of arrhythmia. There were no differences in total mortality and length of stay when comparing any of the vasopressors. More patients suffered arrhythmias with dopamine than with norepinephrine (RR 0.43, 95% CI 0.26 to 0.69) (7).
  • Angiotensin II has been proposed as a possible agent to treat COVID-19-related shock as ARDS causes angiotensin-converting enzyme (ACE) dysfunction leading to vasodilatory shock. However, there are no comparative trials to support Angiotensin II over conventional vasopressors (8).

III.   RECOMMENDED CHOICE OF VASOPRESSORS IN ADULTS WITH COVID-19 AND SHOCK

  • The Surviving Sepsis Campaign and WHO recommend using norepinephrine as a first-line treatment in adults as it is the best studied vasopressor despite no evidence to support its superiority (weak rec, low qual). Epinephrine or vasopressin can be used as a first-line agent if norepinephrine is not available (weak rec, low qual). Dopamine is not recommended due to risk of arrhythmia (strong rec, high qual). Vasopressin should be added as a second line agent to supplement norepinephrine to reach a MAP of 60-65 mmHg in COVID-19 patients (weak rec, moderate qual). If there are signs of cardiac dysfunction despite reaching the appropriate MAP target, consider using dobutamine (weak rec, very low qual). Low-dose corticosteroid therapy is suggested for refractory shock in a COVID-19 patient (1,6).

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

  1. Farkas J. COVID-19 [Internet]. EMCrit Project. 2020 [cited 2020Apr8]. Available from: https://emcrit.org/ibcc/COVID19/?fbclid=IwAR0i40KAZnmlN3g5y510StV1hcq2hBIff4x6K-5Hu4-IjfIE9HL6nlh-tGk#cardiovascular
  2. World Health Organization 2020, editor. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected [Internet]. World Health Organization. World Health Organization; 2020 [cited 2020Apr7]. Available from: https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf
  3. Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. The Lancet Respiratory Medicine. 2020Feb21 [cited 2020Apr7]. Available from: https://www.thelancet.com/action/showPdf?pii=S2213-2600%2820%2930079-5
  4. Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M, et al. Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA. 2020Mar19; [cited 2020Apr7]. Available from: https://jamanetwork.com/journals/jama/fullarticle/2763485
  5. Bhatraju PK, Ghassemieh BJ, Nichols M, Kim R, Jerome KR, Nalla AK, et al. Covid-19 in Critically Ill Patients in the Seattle Region — Case Series. New England Journal of Medicine. 2020Mar30 [cited 2020Apr7]. Available from: https://www.nejm.org/doi/pdf/10.1056/NEJMoa2004500?articleTools=true
  6. Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Medicine. 2020Mar28 [cited 2020Apr7]. Available from: https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/COVID-19
  7. Chow JH, Mazzeffi MA, Mccurdy MT. Angiotensin II for the Treatment of COVID-19–Related Vasodilatory Shock. Anesthesia & Analgesia.
  8. Gamper G, Havel C, Arrich J, Losert H, Pace NL, Mullner M, et al. Vasopressors for hypotensive shock. Cochrane Database of Systematic Reviews. 2016Feb15 [cited 2020Apr7]. Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003709.pub4/full

Disclaimer

The above is intended to serve as a rapidly-created, accessible source of information curated by medical students and healthcare professionals. It is for educational purposes only and is not a complete reference resource. It is not professional medical advice, and is not a substitute for the discretion, judgment, and duties of healthcare professionals. You are solely responsible for evaluating the information above.