Discontinuation of Vasopressin Before Norepinephrine in the Recovery Phase of Septic Shock

Hammond, Drayton A.; McCain, Kelsey; Painter, Jacob T.; Clem, Oktawia A; Cullen, Julia; Brotherton, Amy; Chopra, Divyan; Meena, Nikhil

doi:10.1177/0885066617714209

Cited by 30 publications

(59 citation statements)

References 27 publications

(54 reference statements)

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“…9-11,21,24,28,30 Additional areas with unclear clinical data where cost savings could be realized include initiating vasopressin at a dosage of 0.03 units/min (as opposed to 0.04 units/min) and discontinuing vasopressin prior to norepinephrine. [12][13][14][15][16]31 Although vasopressin up to 0.06 units/min has been used with minimal safety concerns, 24 the seminal trial used 0.03 units/min, 26 which is the guideline-recommended dosage. 1 Evaluations of adjuvant vasopressor strategies for patients in whom norepinephrine monotherapy is inadequate, the discontinuation order of vasoactive medications, and the Those surveyed were asked to indicate their agreement or disagreement with the use of vasopressin for the listed indications for patients with septic shock while considering both available evidence for treatment and cost and while just considering the available evidence.…”

Section: Discussionmentioning

confidence: 99%

“…8 Other initiatives to identify optimal strategies for vasopressin use in septic shock that were evaluated for effects on clinical outcomes have included restriction of vasopressin use in septic shock until the norepinephrine infusion rate is above 50 mcg/min; 9 early, concomitant initiation of norepinephrine and vasopressin; 10,11 and the order of vasopressin discontinuation in resolving septic shock. [12][13][14][15][16] Many of these studies evaluated a small number of clinicians/institutions and failed to evaluate some of the clinical scenarios where vasopressin is often used (eg, severe acidemia, elevated lactate).…”

Section: Introductionmentioning

confidence: 99%

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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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Section: Discussionmentioning

confidence: 99%

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

Self Cite

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“…However, this 4‐hour requirement for maintenance of MAP is more likely to reflect the true transition point from early septic shock to the maintenance phase of septic shock than previously studied 1‐hour requirements for maintaining target MAP. More patients in the early concomitant vasopressin and norepinephrine group had vasopressin discontinued before norepinephrine in the resolving phase of septic shock that would not have any bearing on time to achieving and maintaining target MAP but may have affected duration of both vasopressors and intensive care unit length of stay . Finally, vasopressin was provided at an initial rate of 0.04 units/minute.…”

Section: Discussionmentioning

confidence: 99%

“…More patients in the early concomitant vasopressin and norepinephrine group had vasopressin discontinued before norepinephrine in the resolving phase of septic shock that would not have any bearing on time to achieving and maintaining target MAP but may have affected duration of both vasopressors and intensive care unit length of stay. [24][25] Finally, vasopressin was provided at an initial rate of 0.04 units/minute. The most recent iteration of the Surviving Sepsis Campaign guidelines recommends an initial rate of 0.03 units/minute.…”

Section: Discussionmentioning

confidence: 99%

Prospective Open‐label Trial of Early Concomitant Vasopressin and Norepinephrine Therapy versus Initial Norepinephrine Monotherapy in Septic Shock

et al. 2018

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“…Several studies have demonstrated a higher incidence of hypotension after vasopressin discontinuation compared with NE discontinuation. [29][30][31][32][33] Patient demographics, vasopressor utilization, and clinical outcomes were similar to the overall cohort (Tables S1 and S2, Supporting Information).…”

Section: Discussionmentioning

confidence: 71%

Utilization of vasopressin before and after protocol implementation in a surgical intensive care unit

Smith

Rumbaugh

2019

J Am Coll Clin Pharm

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Introduction Vasopressin is recommended for management of septic shock refractory to fluid challenge and norepinephrine. Controversy exists over when to add vasopressin to norepinephrine treatment. Due to the rising cost of vasopressin and the lack of mortality benefit, the surgical intensive care unit (SICU) at Vanderbilt University Medical Center implemented a protocol for vasopressin use with the purpose of decreasing utilization and cost. Objective The purpose of this study was to characterize vasopressin utilization and evaluate adherence to this protocol. Methods Through a retrospective, observational analysis, adult patients admitted to the SICU who received vasopressin during the 11 months before and after protocol implementation in August 2015 were identified. The primary outcome was vasopressin usage per patient. Secondary outcomes included norepinephrine use, vasopressin cost, and protocol adherence. Results During the pre‐ and post‐protocol periods, 144 of 1788 admitted patients (8%) and 119 of 1845 admitted patients (6%) received vasopressin, respectively. The total duration of vasopressin infusion during hospitalization was similar before and after protocol implementation (20 vs 18 hours, P = 0.526), but vasopressin was both added and discontinued when norepinephrine was infusing at a higher rate (added at 12 vs 18 mcg/min, P < 0.001; discontinued at 0.5 vs 6.0 mcg/min, P < 0.001). Norepinephrine was infused for a longer duration post protocol implementation (31 vs 57 hours, P < 0.001). After implementation, a protocol violation occurred in 59 patients (50%); however, 59% of these were related to vasopressin initiation in the operating room. Thirty‐two patients (27%) experienced a SICU‐related violation, with the most common type being discontinuation of norepinephrine prior to vasopressin. Conclusion Implementation of a vasopressin utilization protocol in a SICU resulted in more selective usage of vasopressin and a similar duration of infusion when it was utilized. Protocol adherence was nearly 75%, exposing some opportunities for continued education and improvement.

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Discontinuation of Vasopressin Before Norepinephrine in the Recovery Phase of Septic Shock

Abstract: Adult patients receiving norepinephrine and vasopressin in the resolving phase of septic shock may be less likely to develop clinically significant hypotension if vasopressin is the final vasopressor discontinued.

Cited by 30 publications

References 27 publications

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

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

Prospective Open‐label Trial of Early Concomitant Vasopressin and Norepinephrine Therapy versus Initial Norepinephrine Monotherapy in Septic Shock

Utilization of vasopressin before and after protocol implementation in a surgical intensive care unit

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