Vasopressor treatment and mortality following nontraumatic subarachnoid hemorrhage: a nationwide electronic health record analysis

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Subarachnoid hemorrhage (SAH) is a devastating cerebrovascular condition, not only due to the effect of initial hemorrhage, but also due to the complication of delayed cerebral ischemia (DCI). While hypertension facilitated by vasopressors is often initiated to prevent DCI, which vasopressor is most effective in improving outcomes is not known. The objective of this study was to determine associations between initial vasopressor choice and mortality in patients with nontraumatic SAH.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors conducted a retrospective cohort study using a large, national electronic medical record data set from 2000–2014 to identify patients with a new diagnosis of nontraumatic SAH (based on ICD-9 codes) who were treated with the vasopressors dopamine, phenylephrine, or norepinephrine. The relationship between the initial choice of vasopressor therapy and the primary outcome, which was defined as in-hospital death or discharge to hospice care, was examined.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>In total, 2634 patients were identified with nontraumatic SAH who were treated with a vasopressor. In this cohort, the average age was 56.5 years, 63.9% were female, and 36.5% of patients developed the primary outcome. The incidence of the primary outcome was higher in those initially treated with either norepinephrine (47.6%) or dopamine (50.6%) than with phenylephrine (24.5%). After adjusting for possible confounders using propensity score methods, the adjusted OR of the primary outcome was higher with dopamine (OR 2.19, 95% CI 1.70–2.81) and norepinephrine (OR 2.24, 95% CI 1.80–2.80) compared with phenylephrine. Sensitivity analyses using different variable selection procedures, causal inference models, and machine-learning methods confirmed the main findings.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>In patients with nontraumatic SAH, phenylephrine was significantly associated with reduced mortality in SAH patients compared to dopamine or norepinephrine. Prospective randomized clinical studies are warranted to confirm this finding.</jats:p></jats:sec>

Machine learning prediction of the adverse outcome for nontraumatic subarachnoid hemorrhage patients

“…19 Finally, our recent work has demonstrated a beneficial association between phenylephrine use and the adverse outcome in this population. 20 Our machine learning predictive models from all six cases (Fig. 3 bottom panel) further confirmed that the phenylephrine use could associate with a reduced probability of adverse outcome after adjusting many other confounding factors in the predictive models.…”

“…Laboratory variables such as glucose (hyperglycemia), anion gap acidosis, renal function, and serum osmolality would also be expected to be associated with adverse clinical outcomes 19 . Finally, our recent work has demonstrated a beneficial association between phenylephrine use and the adverse outcome in this population 20 . Our machine learning predictive models from all six cases (Fig.…”

Investigating the relationship between high-dose norepinephrine administration and the incidence of delayed cerebral infarction in patients with aneurysmal subarachnoid hemorrhage: A single-center retrospective evaluation

“…To date, literature indicating a relationship between high-dose norepinephrine and the development of DCI is scarce. The reason for the rare reporting of adverse effects of norepinephrine on DCI may originate from the fact that many studies report starting to administer vasopressors after a delayed ischemic neurologic deficit or even DCI occurs [ 29 , 38 , 39 ]. However, patients admitted to our institution routinely receive norepinephrine for MAP maintenance right after successful aneurysm treatment (i.e., within 24 hours), which inherently minimizes this potential bias.…”

“…It is well known that excessive use of vasopressors comes with the risk of severe end organ damage, presumably caused by arteriolar and capillary vasoconstriction as well as peaks of systolic arterial blood pressure [28][29][30].…”

Strategies for prevention and treatment of delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage

“…169,170 A more recent retrospective study showed an opposite result: phenylephrine was associated with reduced mortality in aSAH patients as compared to dopamine or norepinephrine. 171 An important limitation of this study was that a change of vasopressor occurred in 33% of patients during the same encounter of care, which was not accounted for in the statistical analysis. Dopamine is another vasopressor often used in studies investigating induced hypertension as treatment for DCI.…”