Impact of Vasopressor Initiation and Discontinuation Sequence on Mortality in Septic Shock: A Retrospective Review

Author Info

Andrew Moyer Cara McDaniel Judah Brown Michael Baram

Corresponding Author

Cara McDaniel
Department of Pharmacy, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA

A B S T R A C T

Background: Little data exists guiding clinicians on how or when to initiate and discontinue the second vasoactive agent in the setting of septic shock refractory to norepinephrine monotherapy. Methods: This retrospective cohort study evaluated patients with a primary diagnosis of septic shock admitted to the intensive care unit receiving norepinephrine in addition to concomitant vasopressors. The primary endpoint was the incidence of all-cause in-hospital mortality when adding adjunctive vasopressors to norepinephrine either before the dose reached 2 mcg/kg/min (early adjunctive vasopressor) or after (late adjunctive vasopressor). Secondary endpoints included the incidence of clinically significant hypotension when discontinuing norepinephrine before or after vasopressin in the same population. Results: Forty-six patients were included (early adjunctive vasopressor [n=36]; late adjunctive vasopressor [n=10]), with a median age of 69 years and APACHE II score of 27. Fewer patients in the early adjunctive vasopressor cohort had malignancy prior to admission (16.7% vs. 60%, p=0.0117), however, more patients were managed in the surgical ICU (44.4% vs. 0%, p=0.0202) with intra-abdominal infection (33.3% vs. 0%, p=0.0439). The primary endpoint of all-cause in-hospital mortality was not statistically different between the early and late adjunctive vasopressor groups (75% vs. 90%, respectively, p=0.4203). Longer ICU and hospital length of stay in the early adjunctive vasopressor cohort was observed (9 days vs 3 days, p=0.0061; 11 days vs 3 days, p=0.0026, respectively). Twenty-two patients were included in analysis of vasopressor discontinuation sequence with no significant differences in mortality, incidence of hypotension, or ICU/hospital length of stay. Conclusion: Among patients with septic shock on multiple vasopressors, addition of adjunctive vasopressor before reaching a norepinephrine dose of 2 mcg/kg/min was associated with longer in-hospital and ICU survival but exhibited no difference in overall mortality. Discontinuation of vasopressin before norepinephrine led to longer total vasopressor duration without a difference in rates of hypotension. Future prospective studies are warranted.

Article Info

Article Type

Research Article

Publication history

Received: Mon 30, Dec 2019
Accepted: Thu 13, Feb 2020
Published: Fri 21, Feb 2020

Copyright

© 2023 Cara McDaniel. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Hosting by Science Repository.
DOI: 10.31487/j.SCR.2020.01.05