Clinical Outcomes of Weight-Based Norepinephrine Dosing in Underweight and Morbidly Obese Patients: A Propensity-Matched Analysis

Kotecha, Aditya; Vallabhajosyula, Saraschandra; Apala, Dinesh Reddy; Frazee, Erin; Iyer, Vivek N.

doi:10.1177/0885066618768180

Cited by 14 publications

(17 citation statements)

References 32 publications

(44 reference statements)

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“…Because of the administrative nature of this cohort, we do not have haemodynamic data, biventricular function, pulmonary hypertension, and quantification of vasoactive medications; all of which are known to influence outcomes in patients with shock. 12,[58][59][60][61][62][63] The declining use of the PAC may have resulted in consequent hesitation in using and/or challenges with interpretation of information. 20 The ICD-9CM codes for a RHC are not validated, and it is possible that those receiving a RHC had a PAC left in situ for continuous monitoring.…”

Section: Discussionmentioning

confidence: 99%

Pulmonary artery catheter use in acute myocardial infarction‐cardiogenic shock

et al. 2020

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Aims The aim of this study is to evaluate the contemporary use of a pulmonary artery catheter (PAC) in acute myocardial infarction-cardiogenic shock (AMI-CS). Methods and results A retrospective cohort of AMI-CS admissions using the National Inpatient Sample (2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014) was identified. Admissions with concomitant cardiac surgery or non-AMI aetiology for cardiogenic shock were excluded. The outcomes of interest were in-hospital mortality, resource utilization, and temporal trends in cohorts with and without PAC use. In the non-PAC cohort, the use and outcomes of right heart catheterization was evaluated. Multivariable regression and propensity matching was used to adjust for confounding. During 2000-2014, 364 001 admissions with AMI-CS were included. PAC was used in 8.1% with a 75% decrease during over the study period (13.9% to 5.4%). Greater proportion of admissions to urban teaching hospitals received PACs (9.5%) compared with urban non-teaching (7.1%) and rural hospitals (5.4%); P < 0.001. Younger age, male sex, white race, higher comorbidity, noncardiac organ failure, use of mechanical circulatory support, and noncardiac support were independent predictors of PAC use. The PAC cohort had higher in-hospital mortality (adjusted odds ratio 1.07 [95% confidence interval 1.04-1.10]), longer length of stay (10.9 ± 10.9 vs. 8.2 ± 9.3 days), higher hospitalization costs ($128 247 ± 138 181 vs. $96 509 ± 116 060), and lesser discharges to home (36.3% vs. 46.4%) (all P < 0.001). In 6200 propensity-matched pairs, in-hospital mortality was comparable between the two cohorts (odds ratio 1.01 [95% confidence interval 0.94-1.08]). Right heart catheterization was used in 12.5% of non-PAC admissions and was a marker of greater severity but did not indicate worse outcomes. Conclusions In AMI-CS, there was a 75% decrease in PAC use between 2000 and 2014. Admissions receiving a PAC were a higher risk cohort with worse clinical outcomes.

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Section: Discussionmentioning

confidence: 99%

Pulmonary artery catheter use in acute myocardial infarction‐cardiogenic shock

et al. 2020

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“…Vasoactive medications are a severity of illness indicator; however, they are incompletely accounted for in scoring systems. More recent data have shown vasoactive medication requirements to be an independent predictor of adverse outcomes [ 11 , 25 – 27 ]. The need for high-dose vasopressors reflects a potentially fatal underlying condition with a high risk of complications, but the direct association remains to be proven.…”

Section: Discussionmentioning

confidence: 99%

“…Existing prognostic scores (APACHE and SOFA) have several limitations [ 31 ]. The APACHE-III does not incorporate either vasopressor use or myocardial dysfunction in sepsis, both of which have mortality implications [ 2 , 3 , 8 , 11 ]. The SOFA score also has some similar limitations as shown in the study by Yadav et al [ 5 ].…”

Section: Discussionmentioning

confidence: 99%

“…This was a retrospective cohort study of adult septic shock patients admitted to all ICUs at the Mayo Clinic in Rochester, Minnesota from January 1, 2010 to December 31, 2015. The characteristics of these ICUs and patient population included in this study have been described previously [ 11 ]. Briefly, the Mayo Clinic is a 2059 bed hospital over two campuses in Rochester Minnesota and has 14 sub-specialty ICUs that are staffed continually by board-certified intensivists.…”

Section: Methodsmentioning

confidence: 99%

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Development and performance of a novel vasopressor-driven mortality prediction model in septic shock

Vallabhajosyula

Jentzer

Kotecha

et al. 2018

Ann. Intensive Care

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BackgroundVasoactive medications are essential in septic shock, but are not fully incorporated into current mortality prediction risk scores. We sought to develop a novel mortality prediction model for septic shock incorporating quantitative vasoactive medication usage.MethodsQuantitative vasopressor use was calculated in a cohort of 5352 septic shock patients and compared using norepinephrine equivalents (NEE), cumulative vasopressor index and the vasoactive inotrope score models. Having best discrimination prediction, log10NEE was selected for further development of a novel prediction model for 28-day and 1-year mortality via backward stepwise logistic regression. This model termed ‘MAVIC’ (Mechanical ventilation, Acute Physiology And Chronic Health Evaluation-III, Vasopressors, Inotropes, Charlson comorbidity index) was then compared to Acute Physiology And Chronic Health Evaluation-III (APACHE-III) and Sequential Organ Failure Assessment (SOFA) scores in an independent validation cohort for its accuracy in predicting 28-day and 1-year mortality.Measurements and main resultsThe MAVIC model was superior to the APACHE-III and SOFA scores in its ability to predict 28-day mortality (area under receiver operating characteristic curve [AUROC] 0.73 vs. 0.66 and 0.60) and 1-year mortality (AUROC 0.74 vs. 0.66 and 0.60), respectively.ConclusionsThe incorporation of quantitative vasopressor usage into a novel ‘MAVIC’ model results in superior 28-day and 1-year mortality risk prediction in a large cohort of patients with septic shock.

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“…23 The impact of higher doses associated with WBD strategies on adverse effects is unknown; however, cumulative norepinephrine exposure has been demonstrated to be an independent predictor of mortality. 27 Another element of pressor agent dosing with variable response was the preferred order of pressor agent discontinuation in patients with resolving shock. If a patient with resolving septic shock were receiving norepinephrine and vasopressin, 57% of respondents would discontinue the vasopressin first.…”

Section: Discussionmentioning

confidence: 99%

Prescribing of Pressor Agents in Septic Shock: A Survey of Critical Care Pharmacists

Smith

Newsome

Tackett

2019

Journal of Pharmacy Technology

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Background: Pressor agents are recognized as high-alert medications by the Institute for Safe Medication Practices, but little evidence is available to guide their use in septic shock. Objective: Characterize the use of pressor agents for septic shock in clinical practice. Methods: A cross-sectional electronic survey assessing demographics, institutional practices, and respondent perceptions related to pressor agents was distributed to the American College of Clinical Pharmacy Critical Care Practice and Research Network. The primary outcome was the use of a weight-based dosing (WBD) strategy versus non-WBD strategy for norepinephrine. Descriptive statistics were used to summarize survey results. Binary logistic regression was performed to determine variables associated with dosing strategies. Results: The survey was completed by 223 respondents. The typical respondent worked in a medical or mixed intensive care unit at a teaching hospital and had training and/or board certification beyond the Doctor of Pharmacy degree. Nearly all respondents (n = 221, 99%) reported norepinephrine as the first-line vasopressor for septic shock; however, 38% used WBD and 60% used non-WBD. In logistic regression, respondents located in the South and practicing at institutions with larger numbers of intensive care unit beds were more likely to use WBD for norepinephrine infusions. Similar findings were observed with epinephrine and phenylephrine. Conclusion: Wide variability exists in prescribing patterns of pressor agents and in pharmacist perceptions regarding best practices. The use of WBD varied based on institutional characteristics and resulted in higher maximum allowable infusion rates of pressor agents. Future research should compare dosing strategies to identify associations with patient outcomes.

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Clinical Outcomes of Weight-Based Norepinephrine Dosing in Underweight and Morbidly Obese Patients: A Propensity-Matched Analysis

Cited by 14 publications

References 32 publications

Pulmonary artery catheter use in acute myocardial infarction‐cardiogenic shock

Pulmonary artery catheter use in acute myocardial infarction‐cardiogenic shock

Development and performance of a novel vasopressor-driven mortality prediction model in septic shock

Prescribing of Pressor Agents in Septic Shock: A Survey of Critical Care Pharmacists

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