Mortality, Morbidity, and Costs After Implementation of a Vasopressin Guideline in Medical Intensive Care Patients With Septic Shock: An Interrupted Time Series Analysis

Bauer, Seth R.; Sacha, Gretchen L.; Reddy, Anita

doi:10.1177/1060028019886306

Cited by 11 publications

(11 citation statements)

References 29 publications

(46 reference statements)

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…The findings of our study appear to contrast previously published data from our health system. An evaluation of a vasoactive agent guideline in patients with septic shock, which recommended vasopressin initiation when the norepinephrine-equivalent dosage exceeded 50 µg/min, did not detect a difference in ICU mortality after implementation (before 43.5% vs after 41.9%; absolute risk difference, –1.5% [95% CI, –7.3% to 4.2%]) (30). These data likely suggest that the guideline implementation was no worse than the prior practice of initiating vasopressin at an average norepinephrine-equivalent dose of 25 µg/min.…”

Section: Discussionmentioning

confidence: 99%

Association of Catecholamine Dose, Lactate, and Shock Duration at Vasopressin Initiation With Mortality in Patients With Septic Shock*

Sacha

Lam

Wang

et al. 2021

Critical Care Medicine

Self Cite

View full text Add to dashboard Cite

OBJECTIVES: To determine the association of catecholamine dose, lactate concentration, and timing from shock onset at vasopressin initiation with in-hospital mortality. DESIGN: Retrospective, observational study using segmented and multivariable logistic regression to evaluate the associations of catecholamine dose, lactate concentration, and timing from shock onset at vasopressin initiation with in-hospital mortality. SETTING: Multiple hospitals within the Cleveland Clinic Health System. PATIENTS: Adult patients who met criteria for septic shock based on the U.S. Centers for Disease Control and Prevention Adult Sepsis Event definition. INTERVENTIONS: All patients received continuous infusion vasopressin as an adjunct to catecholamine vasopressors. MEASUREMENTS AND MAIN RESULTS: In total, 1,610 patients were included with a mean Acute Physiology and Chronic Health Evaluation III 109.0 ± 35.1 and Sequential Organ Failure Assessment 14.0 ± 3.5; 41% of patients survived the hospital admission. At the time of vasopressin initiation, patients had median (interquartile range) lactate concentration 3.9 mmol/L (2.3–7.2 mmol/L), norepinephrine-equivalent dose 25 µg/min (18–40 µg/min), and 5.3 hours (2.1–12.2 hr) elapsed since shock onset. The odds of in-hospital mortality increased 20.7% for every 10 µg/min increase in norepinephrine-equivalent dose up to 60 µg/min at the time of vasopressin initiation (adjusted odds ratio, 1.21 [95% CI, 1.09–1.34]), but no association was detected when the norepinephrine-equivalent dose exceeded 60 µg/min (adjusted odds ratio, 0.96 [95% CI, 0.84–1.10]). There was a significant interaction between timing of vasopressin initiation and lactate concentration (p = 0.02) for the association with in-hospital mortality. A linear association between increasing in-hospital mortality was detected for increasing lactate concentration at the time of vasopressin initiation, but no association was detected for time elapsed from shock onset. CONCLUSIONS: Higher norepinephrine-equivalent dose at vasopressin initiation and higher lactate concentration at vasopressin initiation were each associated higher in-hospital mortality in patients with septic shock who received vasopressin.

show abstract

Section: Discussionmentioning

confidence: 99%

Association of Catecholamine Dose, Lactate, and Shock Duration at Vasopressin Initiation With Mortality in Patients With Septic Shock*

Sacha

Lam

Wang

et al. 2021

Critical Care Medicine

Self Cite

View full text Add to dashboard Cite

show abstract

“…43,44 Given the cost of vasopressin, some centers have elected to limit its initiation until patients are on a higher dose of norepinephrine. 45 Given the untoward effects of norepinephrine in patients with PAH at higher doses, it is reasonable to add on vasopressin before reaching doses suggested for patients with septic shock. 45,46 Phenylephrine should be avoided.…”

Section: Approach To Managementmentioning

confidence: 99%

Considerations for Inotrope and Vasopressor Use in Critically Ill Patients With Pulmonary Arterial Hypertension

Adie

Abdul-Aziz

Ketcham

et al. 2022

Journal of Cardiovascular Pharmacology

View full text Add to dashboard Cite

Pulmonary arterial hypertension (PAH) is a rare and progressive cardiopulmonary disease, characterized by pulmonary vasculopathy. The disease can lead to increase pulmonary arterial pressures and eventual right ventricle failure due to elevated afterload. The prevalence of PAH in patients admitted to the intensive care unit (ICU) is unknown, and pulmonary hypertension (PH) in the ICU is more commonly the result of left heart disease or hypoxic lung injury (PH due to left heart disease and PH due to lung diseases and/or hypoxia, respectively), as opposed to PAH. Management of patients with PAH in the ICU is complex as it requires a careful balance to maintain perfusion while optimizing right-sided heart function. A comprehensive understanding of the underlying physiology and underlying hemodynamics is crucial for the management of this population. In this review, we summarized the evidence for use of vasopressors and inotropes in the management of PH and extrapolated the data to patients with PAH. We strongly believe that the understanding of the hemodynamic consequences of inotropes and vasopressors, especially from data in the PH population, can lead to better management of this complex patient population.

show abstract

“…The findings of the current study emphasize the importance of considering medication costs when developing healthcare cost-containment efforts and are the first to evaluate the price elasticity of demand of vasopressin. Because the utilization of vasopressin continued to rise despite increasing cost, one effort to contain vasopressin-related costs can focus on the convalescence phase of septic shock, specifically the discontinuation order and cessation method of vasopressin, although unable to be directly evaluated in the current study (29)(30)(31). Additionally, the rationale for differences in cost elasticity of demand for medications used in critically ill patients should be further investigated.…”

Section: Vasopressin Utilizationmentioning

confidence: 99%

Association Between Vasopressin Rebranding and Utilization in Patients With Septic Shock*

Sacha

Kiser

Wright

et al. 2021

Critical Care Medicine

Self Cite

View full text Add to dashboard Cite

OBJECTIVES: Vasopressin is suggested as an adjunct to norepinephrine in patients with septic shock. However, after vasopressin was rebranded in November 2014, its cost exponentially increased. Utilization patterns of vasopressin after its rebranding are unclear. The objective of this study was to determine if there is an association between the rebranding of vasopressin in November 2014 and its utilization in vasopressor-dependent patients with severe sepsis or septic shock. DESIGN: Retrospective, multicenter, database study between January 2010 and March 2017. SETTING: Premier Healthcare Database hospitals. PATIENTS: Adult patients admitted to an ICU with severe sepsis or septic shock, who received at least one vasoactive agent for two or more calendar days were included. INTERVENTIONS: The proportion of patients who received vasopressin and vasopressin cost was assessed before and after rebranding, and evaluated with segmented regression. MEASUREMENTS AND MAIN RESULTS: Among 294,733 patients (mean age, 66 ± 15 yr), 27.8% received vasopressin, and ICU mortality was 26.5%. The proportion of patients receiving vasopressin was higher after rebranding (31.2% postrebranding vs 25.8% prerebranding). Before vasopressin rebranding, the quarterly proportion of patients who received vasopressin had an increasing slope (prerebranding slope 0.41% [95% CI, 0.35–0.46%]), with no difference in slope detected after vasopressin rebranding (postrebranding slope, 0.47% [95% CI, 0.29–0.64%]). After vasopressin rebranding, mean vasopressin cost per patient was higher ($527 ± 1,130 vs $77 ± 160), and the quarterly slope of vasopressin cost was higher (change in slope $77.18 [95% CI, $75.73–78.61]). Total vasopressin billed cost postrebranding continually increased by ~$294,276 per quarter from less than $500,000 in Q4 2014 to over $3,000,000 in Q1 2017. CONCLUSIONS: After vasopressin rebranding, utilization continued to increase quarterly despite a significant increase in vasopressin cost. Vasopressin appeared to have price inelastic demand in septic shock.

show abstract

Mortality, Morbidity, and Costs After Implementation of a Vasopressin Guideline in Medical Intensive Care Patients With Septic Shock: An Interrupted Time Series Analysis

Cited by 11 publications

References 29 publications

Association of Catecholamine Dose, Lactate, and Shock Duration at Vasopressin Initiation With Mortality in Patients With Septic Shock*

Association of Catecholamine Dose, Lactate, and Shock Duration at Vasopressin Initiation With Mortality in Patients With Septic Shock*

Considerations for Inotrope and Vasopressor Use in Critically Ill Patients With Pulmonary Arterial Hypertension

Association Between Vasopressin Rebranding and Utilization in Patients With Septic Shock*

Contact Info

Product

Resources

About