Background:


Recent international guidelines suggest the use of vasopressin or terlipressin for vasoplegic shock after cardiac surgery to prevent Acute Kidney Injury (AKI) [1]. A potential role for terlipressin in protecting the kidney in severe septic shock (SS) by decreasing the use of noradrenaline and by decreasing the vasoconstriction of the afferent glomerular arteriole is suggested by our case report.


Case Report:

A 70 year-old women, with medical history of ileostomy because of colonic cancer surgery in 2015, presented faecal peritonitis and severe SS secondary to suture failure of ileostomy closure and required emergent surgery in the immediate postoperative period. Severe vasoplegia occurred intraoperatively, refractory to noradrenalina at 2mcg/kg/min. Terlipressin at 2mcg/kg/h was initiated. Hemodynamic stability and increase in urine output were achieved, which allowed a 50% reduction dose of noradrenaline. Piperacilin/tazobactam and fluconazol were given intraoperatively, which was changed to meropenem and vancomicin the day after. ESBL Escherichia Coli and Enterococcus faecium were observed in the abdominal culture. Vasopressors were stopped 48 hours later. Urine output and Glomerular filtrarion rate (GFR) were well maintained from baseline 84 to 92ml/min in 72h, despite severe SS and high dose of vasopressors. Patient was discharged to the floor one week later.


Discusion:

A recent trial showed a kidney protective effect associated with vasopressin after vasoplegic shock after cardiac surgery. In severe septic shock the benefit of using vasopressin is unclear. We observed a case of severe abdominal refractory SS, who benefit from using terlipressin infusion, leading to a 50% reduction of noradrenaline, as well as, an improvement of urine output and GFR despite high dose of vasopressors. This fact could be explained by the predominant vasoconstrictor effect of terlipressin on efferent glomerular arteriole and therefore an improvement in GFR, unlike noradrenaline or adrenaline effects.

References:

1-Joannidis  M, et al. Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017. Expert opinion of the Working Group on Prevention AKI section, European Society of Intensive Care Medicine. Intensive Care Med 2017; 43:730–749


Learning points:

The use of terlipressin in severe refractory SS is suggested, as may have a role in preventing AKI associated with Severe Septic Shock.



05 / Role of terlipressin in preventing Acute Kidney Injury in refractory severe septic shock.