Epidemiology of Vasopressin Use for Adults with Septic Shock

Abstract

Rationale: Vasopressin may be used to treat vasodilatory hypotension in septic shock, but it is not recommended by guidelines as a first-or second-line agent. Little is known about how often the drug is used currently in septic shock.Objectives: We conducted this study to describe patterns of vasopressin use in a large cohort of U.S. adults with septic shock and to identify patient and hospital characteristics associated with vasopressin use.Methods: This was a retrospective cohort study of adults admitted to U.S. hospitals with septic shock in the Premier healthcare database (July 2008 to June 2013). We performed multilevel mixed-effects logistic regression with hospitals as a random effect to identify factors associated with use of vasopressin alone or in combination with other vasopressors on at least 1 day of hospital admission. We calculated quotients of Akaike Information Criteria (AIC) to determine relative contributions of patient and hospital characteristics to observed variation.Measurements and Main Results: Among 584,421 patients with septic shock in 532 hospitals, 100,923 (17.2%) received vasopressin. A total of 6.1% of patients receiving vasopressin received vasopressin alone, and 93.9% received vasopressin in combination with other vasopressors (up to five vasopressors in 15 different combinations). The mean monthly rate of vasopressin use increased from 14.5 to 19.6% over the study period, representing an average annual relative increase of 8% (P , 0.001). The median hospital rate of vasopressin use for septic shock was 11.7% (range, 0-69.7%). Patient demographic and clinical characteristics, including patient age (adjusted odds ratio, 0.71 for age . 85 yr compared with the reference group of age , 50 yr; 95% confidence interval, 0.69-0.74) and acute respiratory dysfunction (adjusted odds ratio, 3.25; 95% confidence interval, 3.20-3.31), were responsible for the majority of observed variation in vasopressin use (quotient of AICs, 0.56). However, hospital of admission also contributed substantially to observed variation (quotient of AICs, 0.37).Conclusions: Approximately one-fifth of patients with septic shock received vasopressin, but rarely as a single vasopressor. The use of vasopressin has increased over time. The likelihood of receiving vasopressin was strongly associated with the specific hospital to which each patient was admitted.

Predictors of response to fixed-dose vasopressin in adult patients with septic shock

“…It is important to understand that the clinical utilization of AVP and its place in therapy relies on imperfect data, clinical experience, and weak guideline recommendations. Regardless of this, it is commonly used in clinical practice as an adjunct to NE in patients with refractory septic shock [ 22 ]. Its proposed mechanism of action is twofold, by causing V1 receptor-mediated vasoconstriction in some vascular smooth muscle beds [ 23 ], AVP can be utilized as a vasopressor similar to CAs.…”

Septic shock resuscitation in the first hour

“…The hypothesis from sub-group analyses from earlier vasopressin trials (38), is that patients with lower severity of illness may benefit the most. This hypothesis should be tested in the context of increasing vasopressin use in patients with septic shock (39). The circulatory changes in sepsis could also be secondary to abnormalities in the reninangiotensin system and exogenously administered exogenous angiotensin II could be an useful vasopressor in septic shock patients (40).…”

Incidence of hypotension according to the discontinuation order of vasopressors in the management of septic shock: a prospective randomized trial (DOVSS)

“…Vasopressin is effective given its vasoconstrictive action and role in replacing AVP deficiency [ 3 ]. Given these characteristics, there is increasing interest in adding AVP early, as an adjunctive agent to NE [ 4 , 5 ].…”