Arianna Vidger, PharmD,
Clinical Pharmacy Specialist - Critical Care
Indiana University Health Methodist Hospital
Indianapolis, Indiana
Disclosure information not submitted.
Sandra Kuehl, PharmD, BCPS
Clinical Pharmacy Specialist, Medical ICU
Indiana University Health University Hospital, United States
Disclosure information not submitted.
Meghan Blais, BCCCP
Clinical Pharmacist, Adult Critical Care
Nebraska Medicine, United States
Disclosure information not submitted.
Rachel Kruer, BCCCP, PharmD
Clinical Pharmacy Specialist, Critical Care
Indiana University Health
Disclosure information not submitted.
Title: Review of Vasopressin Utilization Following Implementation of a Weaning Protocol
INTRODUCTION/HYPOTHESIS: Vasopressin (AVP) is a commonly used vasopressor in the ICU but is associated with higher cost than catecholamine agents. The objective of this study was to evaluate AVP utilization after implementation of an institutional nursing-driven weaning protocol.
Methods: This retrospective review evaluated patients admitted to the ICU at IU Health from 11/1/18-11/30/18 and 6/1/20-7/21/20 who received AVP for shock. Patients who died on AVP within 24 hours or who were receiving AVP after liver or renal transplant were excluded. In April 2020, AVP order comments were modified to begin AVP at 0.03 units/min and titration instructions were added to allow nursing staff to wean AVP by 0.01 units/minute every 30 minutes if MAP goal is maintained with norepinephrine infusion rate < 15 mcg/min. Use of AVP was compared before and after implementation of the nursing-driven weaning protocol.
Results: One hundred twelve patients were included in the final analysis, 55 before and 57 after implementation. Norepinephrine (NE) was the most common first-line vasopressor in both groups (100/112 patients (89%)), and AVP was most often used as a second-line agent (96/112 patients (86%)). In 2018, the median (IQR) NE dose was 20 mcg/min (12-25) at the time of AVP initiation versus 21 mcg/min (15-30) in 2020 (p=0.277). Median (IQR) NE dose at the time of AVP discontinuation was 0 mcg/min (0-10) versus 6 mcg/min (3-10) (p=0.032). AVP was continued for a median (IQR) of 2.5 days (1.2-3.8) versus 3 days (2-4) (p=0.236). In the 2020 group, 48 patients (84%) met criteria for weaning, at a median (IQR) of 5.2 hours (0-14.6) after starting AVP. Fourteen patients (24%) died while receiving AVP – this was the most common reason for failure to reduce NE or wean AVP. Weaning of AVP started a median (IQR) of 9.5 hours (2.1-18.3) after patients met criteria, and 41/48 patients (85%) eventually discontinued AVP. NE was subsequently increased to ≥20 mcg/min in 5 patients (12%). AVP was increased to ≥0.04 units/min in 25 patients (37%) and NE was titrated off before AVP in 7 patients (10%).
Conclusions: Implementation of a nursing-driven weaning protocol facilitated earlier discontinuation of AVP in relation to concomitant NE infusion rates, without significant increase in background vasopressors.