Musallam Nadine, Altshuler Diana, Merchan Cristian, Zakhary Bishoy, Aberle Caitlin, Papadopoulos John
1 New York University Langone Medical Center, New York, NY, USA.
Ann Pharmacother. 2018 Aug;52(8):733-739. doi: 10.1177/1060028018765187. Epub 2018 Mar 21.
There is little data guiding clinicians on how to discontinue vasopressors among septic shock patients on concomitant norepinephrine (NE) and vasopressin (VP).
To determine the incidence of hypotension within 24 hours of discontinuing NE (NE DC first) versus VP (VP DC first) first in septic shock patients.
This retrospective study evaluated septic shock patients admitted to the medical intensive care unit (MICU) and surgical ICU (SICU) receiving concomitant NE and VP. Receipt of additional vasopressors, mixed shock states, expired or care withdrawn, and NE and VP discontinued simultaneously were exclusion criteria. The primary outcome was incidence of hypotension within 24 hours of first vasopressor discontinuation. Secondary outcomes included time to hypotension, hospital length of stay (LOS), ICU LOS, and ICU mortality.
A total of 80 patients were included (NE DC first [n = 35]; VP DC first [n = 45]), with a median age of 73 years and median modified Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores of 21 and 7, respectively. More patients in the NE DC first group were in the SICU (42.9% vs 20.0%; P = 0.048) with more intra-abdominal infections (40.0% vs 15.6%; P = 0.021) and fewer appropriate empirical antibiotics (62.9% vs 86.7%; P = 0.018). Hypotension within 24 hours of first agent discontinuation was higher in the VP DC first group (28.6% vs 62.2%; P = 0.004), with similar hospital LOS and ICU mortality. Multivariate analysis identified VP DC first as an independent predictor of hypotension (odds ratio = 7.2; CI = 2.3-22.7).
Among septic shock patients on concomitant NE and VP, discontinuation of VP first was associated with an increased incidence of hypotension; future prospective control trials are warranted.
关于如何在同时使用去甲肾上腺素（NE）和血管加压素（VP）的脓毒性休克患者中停用血管升压药，几乎没有数据指导临床医生。
确定在脓毒性休克患者中，先停用NE（先停用NE）与先停用VP（先停用VP）后24小时内低血压的发生率。
这项回顾性研究评估了入住内科重症监护病房（MICU）和外科重症监护病房（SICU）并同时接受NE和VP治疗的脓毒性休克患者。排除标准包括接受额外的血管升压药、混合性休克状态、死亡或放弃治疗，以及同时停用NE和VP。主要结局是首次停用血管升压药后24小时内低血压的发生率。次要结局包括发生低血压的时间、住院时间（LOS）、ICU住院时间和ICU死亡率。
共纳入80例患者（先停用NE [n = 35]；先停用VP [n = 45]），中位年龄为73岁，改良急性生理学与慢性健康状况评估II（APACHE II）评分和序贯器官衰竭评估（SOFA）评分的中位数分别为21分和7分。先停用NE组中更多患者在SICU（42.9%对20.0%；P = 0.048），腹腔内感染更多（40.0%对15.6%；P = 0.021），合适的经验性抗生素使用更少（62.9%对86.7%；P = 0.018）。先停用VP组首次停用药物后24小时内低血压发生率更高（28.6%对62.2%；P = 0.004），住院LOS和ICU死亡率相似。多因素分析确定先停用VP是低血压的独立预测因素（比值比 = 7.2；可信区间 = 2.3 - 22.7）。
在同时使用NE和VP的脓毒性休克患者中，先停用VP与低血压发生率增加相关；未来有必要进行前瞻性对照试验。
