Addition of Vasopressin to Norepinephrine as Independent Predictor of Mortality in Patients with Refractory Septic Shock: An Observational Study

Micek, Scott T.; Shah, Poorvi; Hollands, James M.; Shah, Rina; Shannon, William D.; Kollef, Marin H.

doi:10.1089/sur.2006.003

Cited by 20 publications

(13 citation statements)

References 38 publications

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“…Our finding supports an important clinical issue in the practice of intensive care: critically ill patients treated with a very high dose of vasopressor have a very high mortality rate and CRRT may not improve patients' outcome in our cohort.The association between the highest NE dose and morality can be explained by the poor cardiovascular response to catecholamine (5,16). Similar to our finding, previous studies (6,(17)(18)(19) have also shown a high mortality rate in septic shock patients treated with a very high NE dose. More prospective interventional studies are needed to determine if CRRT before very high vasopressor use in critically ill patients improves patient survival.…”

Section: Discussionsupporting

confidence: 90%

“…The association between the highest NE dose and morality can be explained by the poor cardiovascular response to catecholamine (5,16). Similar to our finding, previous studies (6,17–19) have also shown a high mortality rate in septic shock patients treated with a very high NE dose. More prospective interventional studies are needed to determine if CRRT before very high vasopressor use in critically ill patients improves patient survival.…”

Section: Discussionsupporting

confidence: 90%

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Norepinephrine and Hospital Mortality in Critically Ill Patients Undergoing Continuous Renal Replacement Therapy

Yeh¹,

Chen

Liu³

et al. 2011

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High-dose vasopressor use is associated with increasing mortality in patients with septic shock. We conducted this study to determine if the high-dose of vasopressor used before the initiation of continuous renal replacement therapy (CRRT) is associated with increasing mortality in critically ill patients. We retrospectively reviewed all patients who underwent CRRT in the medical intensive care unit of China Medical University Hospital between 2003 and 2007. The association between mortality and highest vasopressors (dopamine and norepinephrine [NE]) dose used were analyzed using Kaplan-Meier analysis and multivariate Cox regression. A total of 279 patients (170 men and 109 women) treated with CRRT in medical intensive care were reviewed and 237 (84.9%) died. In Kaplan-Meier analysis with log-rank test, dopamine dose of ≥20 µg/kg/min and NE dose of ≥0.3 µg/kg/min were significantly linked to mortality (P = 0.007 and <0.001). In multivariate Cox proportional hazards regression, NE dose of ≥0.3 µg/kg/min, Acute Physiology and Chronic Health Evaluation II score, and low platelet count were independently linked to mortality. The hazard ratios and 95% confidence interval (CI) were 1.771 (95% CI: 1.247-2.516, P = 0.001), 1.035 (95% CI: 1.012-1.058, P = 0.003), and 0.997 (95% CI: 0.996-0.999, P = 0.003), respectively. Critically ill patients treated with very high dose of NE before the initiation of CRRT have a very high mortality rate regardless of the acute kidney injury stage.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionsupporting

confidence: 90%

Norepinephrine and Hospital Mortality in Critically Ill Patients Undergoing Continuous Renal Replacement Therapy

Yeh¹,

Chen

Liu³

et al. 2011

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“…While the VASST investigators found that a subgroup of patients with less severe septic shock had decreased mortality when treated with vasopressin (AVP 27% vs NE 36%, P = 0.05), the significance of this finding has been questioned, as the subgroup population was not powered for this outcome. In practice, vasopressin has been initiated at different time points with varied results that have mostly been reported in retrospective and small, prospective studies …”

Section: Discussionmentioning

confidence: 99%

“…In practice, vasopressin has been initiated at different time points with varied results that have mostly been reported in retrospective and small, prospective studies. 9,16,17,[20][21][22] All values are presented as median (interquartile range). In July 2015, the standard concentration of vasopressin dispensed at our institution was changed from 60 units/100 mL to 20 units/50 mL.…”

Section: Discussionmentioning

confidence: 99%

Utilization of vasopressin before and after protocol implementation in a surgical intensive care unit

Smith

Rumbaugh

2019

J Am Coll Clin Pharm

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Introduction Vasopressin is recommended for management of septic shock refractory to fluid challenge and norepinephrine. Controversy exists over when to add vasopressin to norepinephrine treatment. Due to the rising cost of vasopressin and the lack of mortality benefit, the surgical intensive care unit (SICU) at Vanderbilt University Medical Center implemented a protocol for vasopressin use with the purpose of decreasing utilization and cost. Objective The purpose of this study was to characterize vasopressin utilization and evaluate adherence to this protocol. Methods Through a retrospective, observational analysis, adult patients admitted to the SICU who received vasopressin during the 11 months before and after protocol implementation in August 2015 were identified. The primary outcome was vasopressin usage per patient. Secondary outcomes included norepinephrine use, vasopressin cost, and protocol adherence. Results During the pre‐ and post‐protocol periods, 144 of 1788 admitted patients (8%) and 119 of 1845 admitted patients (6%) received vasopressin, respectively. The total duration of vasopressin infusion during hospitalization was similar before and after protocol implementation (20 vs 18 hours, P = 0.526), but vasopressin was both added and discontinued when norepinephrine was infusing at a higher rate (added at 12 vs 18 mcg/min, P < 0.001; discontinued at 0.5 vs 6.0 mcg/min, P < 0.001). Norepinephrine was infused for a longer duration post protocol implementation (31 vs 57 hours, P < 0.001). After implementation, a protocol violation occurred in 59 patients (50%); however, 59% of these were related to vasopressin initiation in the operating room. Thirty‐two patients (27%) experienced a SICU‐related violation, with the most common type being discontinuation of norepinephrine prior to vasopressin. Conclusion Implementation of a vasopressin utilization protocol in a SICU resulted in more selective usage of vasopressin and a similar duration of infusion when it was utilized. Protocol adherence was nearly 75%, exposing some opportunities for continued education and improvement.

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“…[47][48][49][50][51][52] Two of these deserve an additional comment because they were used in large cohorts of septic shock patients. 50,52 The Sepsis Occurrence in Acutely Ill Patients (SOAP) study was designed to assess the incidence of sepsis and the characteristics of critically ill patients in European ICUs.…”

Section: Observational Studies Of Catecholamines In Septic Shockmentioning

confidence: 99%

Adrenergic Support in Septic Shock: A Critical Review

Póvoa

Carneiro

2010

Hospital Practice

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The definition of septic shock includes sepsis-induced hypotension despite adequate fluid resuscitation, along with the presence of organ perfusion abnormalities, and ultimately cell dysfunction. To restore adequate organ perfusion and cell homeostasis, cardiac output should be restored with volume infusion plus vasopressor agents as indicated. Appropriate arterial pressure for each individual patient and proper arterial oxygen content are key elements to restoring perfusion. Tissue perfusion can be monitored by markers of organ and mitochondrial function, namely urine output, level of consciousness, peripheral skin perfusion, central or mixed venous oxygen saturation, and lactate. The hemodynamic effects of the different vasopressor agents depend on the relative affinity to adrenergic receptors. Those with predominant alpha-agonist activity produce more vasoconstriction (inoconstrictors) while those with predominant beta-agonist stimulation increase cardiac performance (inodilators). The debate about whether one vasopressor agent is superior to another is still ongoing. The Surviving Sepsis Campaign guidelines refer to either norepinephrine or dopamine as the first-choice vasopressor agent to correct hypotension in septic shock. However, recent data from observational and controlled trials have challenged these recommendations concerning different adrenergic agents. As a result, our view on the prescription of vasopressors has changed from a probably oversimplified "one-size-fits-all" approach to a multimodal approach in vasopressor selection.

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Addition of Vasopressin to Norepinephrine as Independent Predictor of Mortality in Patients with Refractory Septic Shock: An Observational Study

Abstract: "Addition of vasopressin to norepinephrine as independent predictor of mortality in patients with refractory septic shock: An observational study."

Cited by 20 publications

References 38 publications

Norepinephrine and Hospital Mortality in Critically Ill Patients Undergoing Continuous Renal Replacement Therapy

Norepinephrine and Hospital Mortality in Critically Ill Patients Undergoing Continuous Renal Replacement Therapy

Utilization of vasopressin before and after protocol implementation in a surgical intensive care unit

Adrenergic Support in Septic Shock: A Critical Review

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