• Gretchen L Sacha and Seth R Bauer.
• Department of Pharmacy, Cleveland Clinic, Case Western Reserve University, Cleveland, OH. Electronic address: sachag@ccf.org.
• Chest. 2023 Nov 1; 164 (5): 121612271216-1227.

Topic ImportanceThis review discusses the rationale for vasopressin use, summarizes the results of clinical trials evaluating vasopressin, and focuses on the timing of vasopressin initiation to provide clinicians guidance for optimal adjunctive vasopressin initiation in patients with septic shock.Review FindingsPatients with septic shock require vasoactive agents to restore adequate tissue perfusion. After norepinephrine, vasopressin is the suggested second-line adjunctive agent in patients with persistent inadequate mean arterial pressure. Vasopressin use in practice is heterogeneous likely because of inconsistent clinical trial findings, the lack of specific recommendations for when it should be used, and the high drug acquisition cost. Despite these limitations, vasopressin has demonstrated price inelastic demand, and its use in the United States has continued to increase. However, questions remain regarding optimal vasopressin use in patients with septic shock, particularly regarding patient selection and the timing of vasopressin initiation.SummaryExperimental studies evaluating the initiation timing of vasopressin in patients with septic shock are limited, and recent observational studies have revealed an association between vasopressin initiation at lower norepinephrine-equivalent doses or lower lactate concentrations and lower mortality.Copyright © 2023 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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