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Article of the Month – October 2020

Comparison of Hemodynamic Responses to Administration of Vasopressin and Norepinephrine Under General Anesthesia: A Systematic Review and Meta-analysis of Randomized Controlled Trials with Trial Sequential Analysis

Authors: Hoshijima H, Mihara T, Denawa Y, Shiga T, Mizuta K.

URL: https://www.jcvaonline.com/action/showPdf?pii=S1053-0770%2820%2930805-3

DOI: https://doi.org/10.1053/j.jvca.2020.08.011

Published: J Cardiothorac Vasc Anesth. 2020 September 10, in press.

Click here to read the article for free, thanks to an agreement among EACTA and Elsevier

Article Description:

  • Intraoperative hypotension can result in multiple organ dysfunction and death secondary to inadequate tissue perfusion during surgery.
  • Norepinephrine has been used to treat intraoperative hypotension via activation of α- and β-adrenergic receptors. However, norepinephrine has well-known side effects, such as increased myocardial oxygen consumption and arrhythmias.
  • Vasopressin acts on vasopressin V1 receptors to cause peripheral vasoconstriction, on vasopressin V2 receptors leading to tubular reabsorption of water, and also can improve left ventricular function, and increase cardiac output and coronary blood flow by increasing coronary perfusion pressure.
  • Vasopressin is usually used to treat intraoperative hypotension in patients unresponsive to norepinephrine, phenylephrine, and other catecholamine-based vasoactive drugs.
  • It is still unclear as to whether vasopressin or norepinephrine is superior in maintaining circulatory dynamics under general anaesthesia.
  • The study question was: “Can vasopressin improve hypotension more effectively than norepinephrine under general anaesthesia?”


  • A meta-analysis including 197 patients from 6 comparative studies between norepinephrine and vasopressin was conducted.
  • The authors calculated the weighted mean difference, with 95% confidence interval (CI) using the random-effects model,
  • and calculated the required information size (RIS) by performing trial sequential analysis (TSA).
  • Vasopressin did not improve hypotension compared with norepinephrine under general anaesthesia. (weighted mean difference = –0.84 mmHg, 95% CI: –5.90 to 4.23, p = 0.75, Cochran Q = 24.6, I2 = 84%)
  • In the TSA, only 35.5% of RIS was achieved. Similarly, vasopressin and norepinephrine were not significantly different in terms of HR, CVP, CO, and CI. In TSA, only 23.7% of the RIS was reached for HR but RIS was almost achieved for CVP and CO.
  • Further research is needed to reach more robust conclusions.

Conclusion:  Vasopressin did not improve hypotension compared with norepinephrine under general anaesthesia.

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