Effects of the discontinuation sequence of norepinephrine and vasopressin on hypotension incidence in patients with septic shock: A meta-analysis

Heart Lung. 2019 Nov-Dec;48(6):560-565. doi: 10.1016/j.hrtlng.2019.05.007. Epub 2019 May 22.


Background: Although the order of vasopressor initiation in patients with septic shock is established, limited information is available on the order of vasopressor discontinuation.

Methods: We performed a meta-analysis of nine studies involving 1245 patients in whom norepinephrine (n = 787) or vasopressin (n = 458) was withdrawn first to compare the risk of hypotension.

Results: The risk of hypotension increased in patients whom vasopressin was withdrawn first (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.3-8.9; p = 0.01). A sensitivity analysis indicated that this effect was observed in four studies with a high risk of bias (OR, 5.4; 95%CI, 1.3-23.5; p = 0.02) and was not observed in five studies with a low risk of bias (OR, 2.4; 95%CI, 0.6-8.4; p = 0.18).

Conclusion: Our results suggest that the risk of hypotension is higher in patients with septic shock in whom vasopressin is withdrawn before norepinephrine.

Keywords: Hypotension; Norepinephrine; Septic shock; Vasopressin.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Humans
  • Hypotension / etiology*
  • Incidence
  • Norepinephrine / administration & dosage*
  • Shock, Septic / drug therapy*
  • Vasoconstrictor Agents / administration & dosage
  • Vasopressins / administration & dosage*


  • Vasoconstrictor Agents
  • Vasopressins
  • Norepinephrine