Seth Bauer, PharmD, FCCM
Clinical Pharmacist
Cleveland Clinic
Lyndhurst, Ohio
Disclosure information not submitted.
Gretchen Sacha, BCCCP, PharmD
Critical Care Clinical Specialist
Cleveland Clinic
Cleveland, Ohio
Disclosure information not submitted.
Xiaofeng Wang, PhD
Biostatistician
Cleveland Clinic Foundation, United States
Disclosure information not submitted.
Vidula Vachharajani, MD, FCCP, FCCM
Professor of Medicine
Cleveland Clinic Lerner College of Medicine
Westlake, Ohio
Disclosure information not submitted.
Title: Association of blood pressure response to vasopressin with clinical trajectory in septic shock
Introduction: Hospital mortality in septic shock exceeds 40%; survivors frequently have a poor clinical trajectory and develop chronic critical illness (CCI). Vasopressors are aimed to improve tissue perfusion and prevent persistent organ dysfunction, a characteristic of CCI. The impact of vasopressin, an often-used catecholamine adjunct, on clinical trajectory is unclear. We primarily designed this study to evaluate the association of vasopressin response with clinical trajectory.
Methods: This retrospective study included patients with septic shock receiving vasopressin as a catecholamine adjunct. Vasopressin blood pressure response was defined as attainment of MAP ≥65 mm Hg with a decrease from baseline in catecholamine dose at 6 hours after vasopressin start. Clinical trajectories were adjudicated as early death (death before ICU day 14), CCI (ICU stay ≥14 days with persistent organ dysfunction), or rapid recovery (ICU stay < 14 days with resolved organ dysfunction). The three trajectories were placed on an ordinal scale with early death considered the worst outcome, CCI next, and rapid recovery the best outcome. The association of vasopressin response with clinical trajectory was assessed with multivariable ordinal logistic regression.
Conclusions: A total of 938 patients were included; most were medical admissions and 426 (45%) were vasopressin responders. A preponderance of patients experienced early death (50%), while 30% developed CCI, and 20% had rapid recovery. Patient characteristics and outcomes differed significantly across clinical trajectories. Early death patients were more frequently vasopressin non-responders (61%), while rapid recovery patients were more frequently vasopressin responders (55%; p< 0.01). After controlling for age, gender, lactate at vasopressin initiation, surgical status, and SOFA, vasopressin response was independently associated with higher odds of developing a better clinical trajectory (OR 1.63; 95% CI 1.26-2.10). Medical patients most frequently developed early death and survivors more commonly developed CCI than rapid recovery; surgical patients developed the three clinical trajectories with similar frequency (p < 0.01). In conclusion, early blood pressure response to vasopressin was associated with improved clinical trajectory in patients with septic shock.