Association Between US Norepinephrine Shortage and Mortality Among Patients With Septic Shock

Vail, Emily A.; Gershengorn, Hayley B.; Hua, May; Walkey, Allan J.; Rubenfeld, Gordon D.; Wunsch, Hannah

doi:10.1001/jama.2017.2841

Cited by 171 publications

(136 citation statements)

References 27 publications

(47 reference statements)

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“…In the NICU, no life-threatening consequences of drug shortages have been reported so far. During the 2011–2012 norepinephrine shortage, an association between the drug shortage and mortality due to septic shock was observed in adult patients [11]. …”

Section: Discussionmentioning

confidence: 99%

Prescription Drug Shortages: Impact on Neonatal Intensive Care

et al. 2018

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Background: Prescription drug shortages have increased significantly during the past two decades and also impact drugs used in critical care and pediatrics. Objectives: To analyze drug shortages affecting medications used in neonatal intensive care units (NICUs). Methods: Drug shortage data for the top 100 NICU drugs were retrieved from the University of Utah Drug Information Service from 2001 to 2016. Data were analyzed focusing on drug class, formulation, reason for shortage, and shortage duration. Results: Seventy-four of the top 100 NICU drugs were impacted by 227 shortages (10.3% of total shortages). Twenty-eight (12.3%) shortages were unresolved as of December 2016. Resolved shortages had a median duration of 8.8 months (interquartile range 3.6–21.3), and generic drugs were involved in 175 (87.9%). An alternative agent was available for 171 (85.8%) drugs but 120 (70.2%) of alternatives were also affected by shortages. Parenteral drugs were involved in 172 (86.4%) shortages, with longer durations than nonparenteral drugs (9.9 vs. 6.4 months, p = 0.022). The most common shortage reason was manufacturing problems (32.2%). Conclusions: Drug shortages affected many agents used in NICUs, which can have quality and safety implications for patient care, especially in extremely low birth weight infants. Neonatologists must be aware of current shortages and implement mitigation strategies to optimize patient care.

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Section: Discussionmentioning

confidence: 99%

Prescription Drug Shortages: Impact on Neonatal Intensive Care

et al. 2018

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“…During norepinephrine shortages from 2008 to 2013 (≥20% decrease from baseline usage), a retrospective cohort study of 26 US hospitals showed an increase in inpatient mortality to 39.6% during the shortage compared with 35.9% with typical norepinephrine use, representing an odds ratio of 1.15 (1.01 to 1.30; P=0.03) 133. Phenylephrine and dopamine were the most common agents used in place of norepinephrine during the shortage.…”

Section: Prevention and Medical Treatmentmentioning

confidence: 99%

“…The selection of the ideal vasopressor in the setting of shock (regardless of AKI status) has been the source of several large scale multicenter trials 103131132133134135. In the setting of SA-AKI, traditional agents such as norepinephrine (noradrenaline), epinephrine, vasopressin, and dopamine, as well as more novel agents such as angiotensin II and levosimendan, have been investigated.…”

Section: Prevention and Medical Treatmentmentioning

confidence: 99%

Sepsis associated acute kidney injury

Poston

Koyner

2019

BMJ

514

381

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Sepsis is defined as organ dysfunction resulting from the host’s deleterious response to infection. One of the most common organs affected is the kidneys, resulting in sepsis associated acute kidney injury (SA-AKI) that contributes to the morbidity and mortality of sepsis. A growing body of knowledge has illuminated the clinical risk factors, pathobiology, response to treatment, and elements of renal recovery that have advanced our ability to prevent, detect, and treat SA-AKI. Despite these advances, SA-AKI remains an important concern and clinical burden, and further study is needed to reduce the acute and chronic consequences. This review summarizes the relevant evidence, with a focus on the risk factors, early recognition and diagnosis, treatment, and long term consequences of SA-AKI. In addition to literature pertaining to SA-AKI specifically, pertinent sepsis and acute kidney injury literature relevant to SA-AKI was included.

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“…Vasopressin is recommended as an adjunctive agent to norepinephrine to raise mean arterial pressure or to reduce norepinephrine requirements in patients with septic shock . Approximately 30% of adult patients experiencing septic shock received vasopressin in the second quarter of 2013, however, more recent utilization is unknown . In September 2012, Par Pharmaceuticals submitted a New Drug Application to the United States Food and Drug Administration for an intravenous vasopressin product, which was approved in December 2014 .…”

Section: Introductionmentioning

confidence: 99%

Perceptions regarding vasopressin use and practices in septic shock, and cost containment strategies

Hammond

Rech

Daley

et al. 2019

J Am Coll Clin Pharm

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Background Clinician preferences and practices regarding appropriate vasopressin use in light of its increased acquisition cost secondary to rebranding has not been evaluated or described since the most recent iteration of the Surviving Sepsis Campaign Guideline was published. Objective To assess vasopressin cost containment initiatives and pharmacists' opinions regarding appropriate vasopressin use. Methods A scenario‐based survey was distributed to critical care and emergency medicine pharmacists. Responses were characterized using frequency and descriptive statistics. Categorical variables between those who implemented changes (Vasopressin Cost Consideration) and those who did not (Usual Care) were compared using chi‐square or Fisher's exact tests. McNemar's test was used to compare responses in clinical scenarios between Vasopressin Cost Consideration and Usual Care groups. Results Among 1757 pharmacists surveyed, 200 (11.3%) responded. When respondents considered vasopressin cost and evidence (vs evidence alone), fewer respondents would use vasopressin adjunctively with norepinephrine (21% vs 26.6%, P = 0.031), to raise mean arterial pressure compared with epinephrine (65.2% vs 72.3%, P = 0.012), or to reduce norepinephrine infusion rates (71.4% vs 81.4%, P < 0.001), but would use with steroids (62.4% vs 28.3%, P < 0.001). Most (72%) respondents had implemented vasopressin cost containment and/or education initiatives. The Vasopressin Cost Consideration group respondents were more likely to initiate vasopressin at 0.03 units/minute without titrating (47.9% vs 33.9%, P = 0.045). Conclusion Since vasopressin was generically rebranded, most institutions have implemented at least one initiative to reduce vasopressin use and/or educate clinicians about its appropriate use. When vasopressin acquisition costs were considered, pharmacists recommended its use less frequently, particularly in clinical scenarios where its use is controversial.

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Association Between US Norepinephrine Shortage and Mortality Among Patients With Septic Shock

Abstract: Among patients with septic shock in US hospitals affected by the 2011 norepinephrine shortage, the most commonly administered alternative vasopressor was phenylephrine. Patients admitted to these hospitals during times of shortage had higher in-hospital mortality.

Cited by 171 publications

References 27 publications

Prescription Drug Shortages: Impact on Neonatal Intensive Care

Prescription Drug Shortages: Impact on Neonatal Intensive Care

Sepsis associated acute kidney injury

Perceptions regarding vasopressin use and practices in septic shock, and cost containment strategies

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