Shock - Emerging treatments | BMJ Best Practice

Angiotensin II for treatment of vasodilatory shock

A randomised controlled trial (RCT) of 321 patients showed that angiotensin II increased blood pressure in patients with vasodilatory shock when they did not respond to high doses of conventional vasopressors. The trial was not sufficiently powered to determine an improvement in survival with functional neurological outcome.[179] The European Medicines Agency has approved angiotensin II for the treatment of refractory hypotension in adults with septic or other distributive shock who remain hypotensive despite fluid resuscitation and application of catecholamines and other vasopressors.

Extracorporeal membrane oxygenation (ECMO)

ECMO may play a role in management of cardiogenic shock by providing mechanical pulmonary and circulatory support when the shock state is refractory to medical and surgical therapy.[180][181][182]

Vasopressin plus catecholamine vasopressor for distributive shock

In one systematic review and meta-analysis of RCTs, the addition of vasopressin to a catecholamine vasopressor significantly reduced the risk of atrial fibrillation in patients with distributive shock compared with catecholamine alone (high-quality evidence).[183] Studies included in the review rarely provided a detailed description of the method in which vasopressors were initiated, titrated, and weaned.

Levosimendan

Levosimendan, an inotrope, increases cardiac contractility by enhancing the sensitivity of the myocardium to calcium and selectively inhibiting phosphodiesterase 3.[14] Low-quality evidence suggests that levosimendan may reduce short-term mortality in patients with cardiogenic shock or low cardiac output syndrome compared with dobutamine.[184] During long-term follow-up, levosimendan did not reduce mortality compared with dobutamine.[184] In patients with septic shock, levosimendan may increase cardiac index and left ventricular ejection fraction but, compared with dobutamine, it does not reduce mortality.[185][186]

Polymyxin B haemoperfusion

Meta-analysis suggests that polymyxin-B haemoperfusion, a technique that removes circulating endotoxins extracorporeally using a polymyxin-B-adsorbing cartridge, may reduce mortality in patients with severe sepsis and septic shock in specific disease severity sub-groups.[187] However, in one subsequent RCT, targeted polymyxin B haemoperfusion did not reduce 28-day mortality in patients with septic shock (high acuity, and at higher risk of death than patients enrolled in prior trials) and elevated endotoxin level.[188]