Background: Current guidelines recommend norepinephrine as the first-line vasopressor in septic shock followed by addition of vasopressin to achieve a goal mean arterial pressure. Limited evidence exists evaluating how the timing of vasopressin addition affects clinical outcomes in septic shock. Objective: The objective of this study was to determine whether the timing of the addition of vasopressin to norepinephrine affects shock resolution. Methods: This was a multi-site, single system, retrospective cohort, institutional review board (IRB)-approved study examining adult patients with septic shock who received norepinephrine and vasopressin. Patients were divided and statistically analyzed in two subgroups: early vasopressin addition (<3 hours) and late vasopressin addition (≥3 hours). The primary outcome was time to shock resolution, defined as vasopressor free for at least 24 hours. Secondary outcomes included norepinephrine dose at 3 hours after initiation of vasopressin, in-hospital mortality, and intensive care unit length of stay. Results: A total of 243 patients were included in this study. A statistically significant decrease in time to shock resolution was observed in the early vasopressin addition group compared to the late vasopressin addition group (37.6 hours vs 60.7 hours; adjusted hazard ratio [HR]: 2.07 [1.48-2.89; P = <0.001]). The early addition of vasopressin did not affect norepinephrine dose or in-hospital mortality but did lead to a decreased intensive care unit (ICU) length of stay (4.3 days vs 5.3 days, P = 0.02). Conclusion and Relevance: Addition of vasopressin to norepinephrine within 3 hours was associated with a faster time to shock resolution. These findings suggest a potential for improved clinical outcomes with earlier vasopressin addition.

This study identified the potential need for changes in our health system protocol with regards to patients at risk for ARC. Patients weighing 70-89 kg with a CrCl > 130 mL/min may benefit from an increase in dosing frequency. Further studies to evaluate appropriate vancomycin dosing in patients who failed to achieve an initial therapeutic trough are needed.

ethylene glycol toxicity can be fatal without prompt treatment. treatment options may include ethanol, fomepizole, and intermittent hemodialysis (IHD). IHD is usually preferred; however, depending on a patient's clinical presentation continuous renal replacement therapy (CRRt) for the removal of ethylene glycol may be desirable. a 36-year-old male presented after transfer from a referring hospital with coma, severe acidosis, and elevated osmolal gap. With suspicion of toxic alcohol poisoning, an ethylene glycol serum concentration was ordered and eventually resulted at 163 mg/dL. the care team decided to initiate treatment with fomepizole and IHD. Due to severe hypotension requiring vasopressors, the patient underwent CRRt in lieu of IHD. We further describe the rapid clearance of ethylene glycol with concurrent fomepizole and CRRt. High flow rate continuous venovenous hemodiafiltration (CVVHDF) combined with fomepizole, removes ethylene glycol from the body in a timely manner.

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