Russel J Roberts1, Todd A Miano2, Drayton A Hammond3, Gourang P Patel4, Jen-Ting Chen5, Kristy M Phillips1, Natasha Lopez1, Kianoush Kashani6,7, Nida Qadir8, Charles B Cairns9, Kusum Mathews10, Pauline Park11, Akram Khan12, James F Gilmore13, Anne Rain Tanner Brown14, Betty Tsuei15, Michele Handzel16, Alfredo Lee Chang17, Abhijit Duggal18, Michael Lanspa19, James Taylor Herbert20, Anthony Martinez21, Joseph Tonna22, Mahmoud A Ammar23, Lama H Nazer24, Mojdeh Heavner25, Erin Pender26, Lauren Chambers27, Michael T Kenes28, David Kaufman29, April Downey30, Brent Brown31, Darlene Chaykosky32, Armand Wolff33, Michael Smith34, Katie Nault35, Michelle N Gong5, Jonathan E Sevransky36, Ishaq Lat37. 1. Department of Pharmacy, Massachusetts General Hospital, Boston, MA. 2. Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 3. Department of Pharmacy, Rush Medical College, Rush University Medical Center, Chicago, IL. 4. Department of Pharmacy, University of Chicago Medical Center, Chicago, IL. 5. Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY. 6. Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN. 7. Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN. 8. Division of Pulmonary and Critical Care Medicine, University of California Los Angeles, Los Angeles, CA. 9. Department of Emergency Medicine, University of Arizona, Tucson, AZ. 10. Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Emergency Medicine, Mount Sinai Health System, New York, NY. 11. Division of Acute Care Surgery, University of Michigan, Ann Arbor, MI. 12. Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR. 13. Department of Pharmacy, Brigham and Women's Hospital, Boston, MA. 14. Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, TX. 15. Section of General Surgery, University of Cincinnati Department of Surgery, Cincinnati, OH. 16. Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY. 17. Division of Pulmonary and Critical Care, Department of Medicine, University of Southern California, Los Angeles, CA. 18. Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH. 19. Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Healthcare, Salt Lake City, UT. 20. Division of Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, NC. 21. Division of Critical Care, St Agnes Hospital, Baltimore, MD. 22. Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT. 23. Department of Pharmacy, Yale-New Haven Health, New Haven, CT. 24. Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan. 25. Department of Pharmacy Practice and Science, University of Maryland Medical Center, Baltimore, MD. 26. Department of Pharmacy, Truman Medical Center, Kansas City, MO. 27. Department of Pharmacy Services, Vidant Medical Center, Greenville, NC. 28. Department of Pharmacy, Wake Forest Baptist Health, Winston-Salem, NC. 29. Division of Pulmonary, Critical Care, and Sleep Medicine, New York University, New York, NY. 30. Department of Pharmacy, Ohio Health Riverside Methodist Hospital, Columbus, OH. 31. Department of Medicine, Pulmonary and Critical Care, University of Oklahoma Health Sciences Center, Oklahoma City, OK. 32. Department of Pharmacy, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA. 33. Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Bridgeport Hospital, Bridgeport, CT. 34. Department of Pharmacy, Lake Region General Healthcare, Laconia, NH. 35. Department of Pharmacy, Lahey Hospital Medical Center, Burlington, MA. 36. Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University Hospital, Atlanta, GA. 37. Department of Pharmacy, Shirley Ryan Abilitylab, Chicago, IL.
Abstract
OBJECTIVES: The objectives of this study were to: 1) determine the association between vasopressor dosing intensity during the first 6 hours and first 24 hours after the onset of septic shock and 30-day in-hospital mortality; 2) determine whether the effect of vasopressor dosing intensity varies by fluid resuscitation volume; and 3) determine whether the effect of vasopressor dosing intensity varies by dosing titration pattern. DESIGN: Multicenter prospective cohort study between September 2017 and February 2018. Vasopressor dosing intensity was defined as the total vasopressor dose infused across all vasopressors in norepinephrine equivalents. SETTING: Thirty-three hospital sites in the United States (n = 32) and Jordan (n = 1). PATIENTS: Consecutive adults requiring admission to the ICU with septic shock treated with greater than or equal to 1 vasopressor within 24 hours of shock onset. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Out of 1,639 patients screened, 616 were included. Norepinephrine (93%) was the most common vasopressor. Patients received a median of 3,400 mL (interquartile range, 1,851-5,338 mL) during the 24 hours after shock diagnosis. The median vasopressor dosing intensity during the first 24 hours of shock onset was 8.5 μg/min norepinephrine equivalents (3.4-18.1 μg/min norepinephrine equivalents). In the first 6 hours, increasing vasopressor dosing intensity was associated with increased odds ratio of 30-day in-hospital mortality, with the strength of association dependent on concomitant fluid administration. Over the entire 24 hour period, every 10 μg/min increase in vasopressor dosing intensity was associated with an increased risk of 30-day mortality (adjusted odds ratio, 1.33; 95% CI, 1.16-1.53), and this association did not vary with the amount of fluid administration. Compared to an early high/late low vasopressor dosing strategy, an early low/late high or sustained high vasopressor dosing strategy was associated with higher mortality. CONCLUSIONS: Increasing vasopressor dosing intensity during the first 24 hours after septic shock was associated with increased mortality. This association varied with the amount of early fluid administration and the timing of vasopressor titration.
OBJECTIVES: The objectives of this study were to: 1) determine the association between vasopressor dosing intensity during the first 6 hours and first 24 hours after the onset of septic shock and 30-day in-hospital mortality; 2) determine whether the effect of vasopressor dosing intensity varies by fluid resuscitation volume; and 3) determine whether the effect of vasopressor dosing intensity varies by dosing titration pattern. DESIGN: Multicenter prospective cohort study between September 2017 and February 2018. Vasopressor dosing intensity was defined as the total vasopressor dose infused across all vasopressors in norepinephrine equivalents. SETTING: Thirty-three hospital sites in the United States (n = 32) and Jordan (n = 1). PATIENTS: Consecutive adults requiring admission to the ICU with septic shock treated with greater than or equal to 1 vasopressor within 24 hours of shock onset. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Out of 1,639 patients screened, 616 were included. Norepinephrine (93%) was the most common vasopressor. Patients received a median of 3,400 mL (interquartile range, 1,851-5,338 mL) during the 24 hours after shock diagnosis. The median vasopressor dosing intensity during the first 24 hours of shock onset was 8.5 μg/min norepinephrine equivalents (3.4-18.1 μg/min norepinephrine equivalents). In the first 6 hours, increasing vasopressor dosing intensity was associated with increased odds ratio of 30-day in-hospital mortality, with the strength of association dependent on concomitant fluid administration. Over the entire 24 hour period, every 10 μg/min increase in vasopressor dosing intensity was associated with an increased risk of 30-day mortality (adjusted odds ratio, 1.33; 95% CI, 1.16-1.53), and this association did not vary with the amount of fluid administration. Compared to an early high/late low vasopressor dosing strategy, an early low/late high or sustained high vasopressor dosing strategy was associated with higher mortality. CONCLUSIONS: Increasing vasopressor dosing intensity during the first 24 hours after septic shock was associated with increased mortality. This association varied with the amount of early fluid administration and the timing of vasopressor titration.
Authors: Mahmoud A Ammar; Abdalla A Ammar; Patrick M Wieruszewski; Brittany D Bissell; Micah T Long; Lauren Albert; Ashish K Khanna; Gretchen L Sacha Journal: Ann Intensive Care Date: 2022-05-30 Impact factor: 10.318
Authors: Meiping Wang; Bo Zhu; Li Jiang; Ying Wen; Bin Du; Wen Li; Guangxu Liu; Wei Li; Jing Wen; Yan He; Xiuming Xi Journal: BMJ Open Date: 2020-12-28 Impact factor: 2.692
Authors: Daniel De Backer; Nadia Aissaoui; Maurizio Cecconi; Michelle S Chew; André Denault; Ludhmila Hajjar; Glenn Hernandez; Antonio Messina; Sheila Nainan Myatra; Marlies Ostermann; Michael R Pinsky; Jean-Louis Teboul; Philippe Vignon; Jean-Louis Vincent; Xavier Monnet Journal: Intensive Care Med Date: 2022-08-10 Impact factor: 41.787