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

Abstract

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.