Predictors of response to fixed-dose vasopressin in adult patients with septic shock

Gretchen L Sacha, Simon W Lam, Abhijit Duggal, Heather Torbic, Stephanie N Bass, Sarah C Welch, Robert S Butler, Seth R Bauer, Gretchen L Sacha, Simon W Lam, Abhijit Duggal, Heather Torbic, Stephanie N Bass, Sarah C Welch, Robert S Butler, Seth R Bauer

Abstract

Background: Vasopressin is often utilized for hemodynamic support in patients with septic shock. However, the most appropriate patient to initiate therapy in is unknown. This study was conducted to determine factors associated with hemodynamic response to fixed-dose vasopressin in patients with septic shock.

Methods: Single-center, retrospective cohort of patients receiving fixed-dose vasopressin for septic shock for at least 6 h with concomitant catecholamines in the medical, surgical, or neurosciences intensive care unit (ICU) at a tertiary care center. Patients were classified as responders or non-responders to fixed-dose vasopressin. Response was defined as a decrease in catecholamine dose requirements and achievement of mean arterial pressure ≥ 65 mmHg at 6 h after initiation of vasopressin.

Results: A total of 938 patients were included: 426 responders (45%), 512 non-responders (55%). Responders had lower rates of in-hospital (57 vs. 72%; P < 0.001) and ICU mortality (50 vs. 68%; P < 0.001), and increased ICU-free days at day 14 and hospital-free days at day 28 (2.3 ± 3.8 vs. 1.6 ± 3.3; P < 0.001 and 4.2 ± 7.2 vs. 2.8 ± 6.0; P < 0.001, respectively). On multivariable analysis, non-medical ICU location was associated with increased response odds (OR 1.70; P = 0.0049) and lactate at vasopressin initiation was associated with decreased response odds (OR 0.93; P = 0.0003). Factors not associated with response included APACHE III score, SOFA score, corticosteroid use, and catecholamine dose.

Conclusion: In this evaluation, 45% responded to the addition of vasopressin with improved outcomes compared to non-responders. The only factors found to be associated with vasopressin response were ICU location and lactate concentration.

Keywords: Catecholamines; Norepinephrine; Sepsis; Septic shock; Vasopressin; Vasopressors.

Figures

Fig. 1
Fig. 1
Patient inclusion and exclusion tree. There were 2555 patients screened for inclusion into the study. Of the screened patients, 1506 patients did not meet initial inclusion criteria and 111 met exclusion criteria leaving 938 patients included in the evaluation. AVP arginine vasopressin; CA catecholamine; EMR electronic medical record; OR operating room
Fig. 2
Fig. 2
Patient results over time for vasopressin responders and non-responders. a Catecholamine dose from -24 h to 72 h after vasopressin initiation. Responders had significantly lower catecholamine doses at 2, 3, 6, 12, 24 and 48 h after vasopressin initiation compared to non-responders. b Change in MAP from time 0 to 72 h after vasopressin initiation. Responders had significantly higher degrees of MAP change at 3 and 24 h after vasopressin initiation compared to non-responders. c Changes in lactate concentration from -24 h to 72 h after vasopressin initiation. Responders had significantly lower lactate concentrations at 2, 3, 6, 12, 24, and 48 h compared to nonresponders. d ScvO2 from -24 h to 72 h after vasopressin initiation. There was no difference in ScvO2 between responders and non-responders at any time point evaluated. MAP mean arterial pressure; NR non-responders; R responders; ScvO2 central venous oxygen saturation. Data are means, with error bars indicating standard deviation. ◊ P < 0.001

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