.jpg "Ryota Sato, MD photo")
Ryota Sato, MD
Staff Intensivist
The Queens Medical Center
Honolulu, Hawaii
Disclosure information not submitted.
Ashish Khanna, MD, FCCP, FASA,FCCM
Anesthesiologist & Intensivist, Associate Professor of Anesthesiology
Wake Forest Baptist Medical Center
Winston Salem, North Carolina
Disclosure information not submitted.
Simon Mucha, MD, FACP
Physician
Cleveland Clinic Foundation, United States
Disclosure information not submitted.
Abhijit Duggal, MD, MPH, MSc, FACP
Assistant Professor
Cleveland Clinic Foundation, United States
Disclosure information not submitted.
Siddharth Dugar, MD, FCCM
Associate Staff
Cleveland Clinic Foundation
Cleveland, Ohio
Disclosure information not submitted.
Title: Norepinephrine Equivalent Dose Is Strongly Associated With In-Hospital Mortality in Septic Shock
Introduction: Refractory shock has been defined by the vasopressor requirement. On the other hand, septic shock sometimes requires inotropic support for concomitant myocardial dysfunction. The vasoactive-inotropic score (VIS) quantifies the amount of vasopressor and inotropic support. This study aimed to compare the maximum VIS and norepinephrine equivalent (NEE) dose in the first 24 hours of septic shock for the prediction of in-hospital mortality and explore the optimal definition of refractory septic shock.
Methods: This single-center, retrospective cohort study included patients with septic shock admitted to the medical intensive care unit at a quaternary center from 01/01/2011 to 12/31/2020. We performed receiver operating characteristic analysis to assess the prediction accuracy for in-hospital mortality of maximum VIS [= NE*100 + vasopressin*10,000 + milrinone*10 + epinephrine*100 + dobutamine + dopamine (all in µg/kg/min except vasopressin in units/kg/min)] and maximum NEE dose [= NE + epinephrine + phenylephrine/10 + dopamine/100 + vasopressin*2.5 (all in µg/kg/min except vasopressin in units/min)] in the first 24 hours of septic shock. We, then, established three NEE categories: Group1: < 0.2, Group2: 0.2-0.4, Group3: > 0.4 (µg/kg/min). A Cox proportional hazards regression model was used to investigate the hazard ratio (HR) of in-hospital mortality in each category.
Results: A total of 3,375 patients with septic shock were included. Median maximum VIS and NEE dose in the first 24 hours were 35 and 0.32 (µg/kg/min). NEE dose showed significantly better prediction accuracy than VIS for in-hospital mortality [NEE dose; area under the curve (AUC): 0.78, 95% confidence interval (CI): 0.76-0.79 versus. VIS; AUC: 0.74, 95% CI: 0.73-0.76, p< 0.001] with a NEE dose-cutoff of 0.38 (µg/kg/min). In-hospital mortalities of each group (Group1: N=1,165, Group2: N=797, and Group3: N=1,413) were 16.7%, 29.9% (HR: 1.7, 95% CI: 1.4-2.1, p< 0.001), and 65.0% (HR: 4.9, 95%CI: 4.2-5.7, p< 0.001), respectively.
Conclusion: Maximum NEE dose in the first 24 hours of septic shock had significantly better predictive accuracy than VIS for in-hospital mortality with the cut-off of 0.38 (µg/kg/min). Therefore, NEE of 0.4 µg/kg/min may be useful to define the refractory septic shock.