Daniel Arellano, ACNP, CCRN, PhD, RN
Advanced Practice Nurse
University of Texas MD Anderson Cancer Center
Houston
Disclosure information not submitted.
Hanneman Sandra, PhD, RN, FAAN
Jerold B. Katz Distinguished Professor for Nursing Research
University of Texas Health Science Center at Houston Cizik School of Nursing
Houston, Texas, United States
Disclosure information not submitted.
Joseph Nates, MBA, MD
Professor, Deputy Chair, Director ICUs
University of Texas MD Anderson Center
Bellaire, Texas, United States
Disclosure information not submitted.
Title: A Descriptive Study of Vasopressor Titration in Medical ICU Patients with Septic Shock
Introduction: Vasopressor therapy in patients with septic shock can lead to harmful effects. Adverse effects associated with vasopressor use include ischemia and arrhythmias. Weaning patients off vasopressors as soon as possible should help improve outcomes in view of lower complications. The goal of our study was to describe vasopressor titration in patients with septic shock.
Methods: Single-center descriptive study of 60 intensive care unit (ICU) patients to calculate rates for events of failure to titrate, incorrect titration, and correct titration in 15- minute intervals for the duration of vasopressor therapy. Total hospital and ICU days, mortality rate, vasopressor dose and time, and the impact of hydrocortisone on vasopressor use were examined.
Results: During the total vasopressor infusion time of 2598 hours, 5395 failure to titrate events were noted. There were 316 incorrect titrations, 704 correct titrations, and 3977 time intervals when titration was not indicated. Converting the aggregate titration opportunities to an hourly rate, and based on documentation of mean arterial blood pressure at 15-minute intervals, the failure-to-titrate hourly rate was 50%, the incorrect- titration rate was 2%, and the correct-titration hourly rate was 48% (correct titration and titration not indicated). Patients with higher acuity score were more likely to receive corticosteroids than those with lower acuity score. When controlling for acuity of illness with APACHE II or SOFA scores, Cox regression showed no meaningful difference (p =.18 for APACHE II and p = .31 for SOFA) in time on vasopressors between patients receiving and those not receiving corticosteroids.
Conclusions: The findings of this study showed that, in one MICU, nurses made appropriate titration decisions nearly half the time patients with septic shock were on vasopressor therapy. Incorrect titration was relatively rare. However, nurses failed to execute titration a considerable percentage of time, which would be expected to prolong vasopressor therapy, thereby placing patients at risk for adverse effects. Prolonged vasopressor therapy could also increase ICU length of stay, which would place the patient at a higher risk of hospital complications and a higher cost of care.