Addition of vasopressin to norepinephrine as independent predictor of mortality in patients with refractory septic shock: an observational study.
OBJECTIVE
To identify predictors of 28-day mortality among patients with refractory septic shock treated with norepinephrine with or without vasopressin.


METHODS
Prospective observational cohort study.


METHODS
A 1,200-bed academic medical center.


METHODS
One hundred thirty-seven patients with septic shock treated with norepinephrine with or without vasopressin.


METHODS
None.


RESULTS
The 28-day mortality rate was 37.2% (n = 51). By multivariate analysis, significant predictors of death were norepinephrine plus vasopressin administration (adjusted odds ratio [AOR], 13.96; 95% confidence interval [CI] 6.47, 30.08; p = 0.001), lack of goal-directed fluid administration during initial resuscitation (AOR 15.82; 95% CI 6.16, 40.61; p = 0.003), inappropriate initial antimicrobial therapy (AOR 8.95; 95% CI 2.93, 27.33; p = 0.05), and higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (AOR 1.14; 95% CI 1.07, 1.21; p = 0.033). Patients who received norepinephrine plus vasopressin (n = 68) had a significantly higher mortality rate than patients managed with norepinephrine alone (n = 69) 28 days after the initiation of vasopressors (54.4% vs. 20.3%; p < 0.001). This finding was confirmed in patients matched optimally across treatment groups.


CONCLUSIONS
Our study found an association between the use of norepinephrine plus vasopressin and 28-day mortality in refractory septic shock. In view of its known mechanism of action, vasopressin contributed to this excess mortality. Further recommendations regarding the use of vasopressin await the results of large randomized trials evaluating its efficacy and safety for septic shock.
Micek
Scott T
ST
Department of Pharmacy, Barnes-Jewish Hospital, St Louis, MO, USA.
Shah
Poorvi
P
Hollands
James M
JM
Shah
Rina A
RA
Shannon
William D
WD
Kollef
Marin H
MH
D018806:APACHE; D000328:Adult; D000368:Aged; D004338:Drug Combinations; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D008923:Missouri / Q000453:epidemiology; D009638:Norepinephrine / Q000627:therapeutic use*; D016017:Odds Ratio; D011446:Prospective Studies; D012772:Shock, Septic / Q000188:drug therapy* / Q000401:mortality*; D014662:Vasoconstrictor Agents / Q000009:adverse effects / Q000627:therapeutic use*; D014667:Vasopressins / Q000009:adverse effects* / Q000627:therapeutic use
D004338:Drug Combinations; D014662:Vasoconstrictor Agents; D014667:Vasopressins; D009638:Norepinephrine