title: Discontinuation of vasopressin before norepinephrine increases the incidence of hypotension in patients recovering from septic shock: a retrospective cohort study.
abstract: OBJECTIVE
  There are little data regarding the discontinuation of vasoactive medications in patients recovering from septic shock. We designed this retrospective cohort study to evaluate the incidence of hypotension based on the order of removal of norepinephrine (NE) and vasopressin (AVP) in patients receiving concomitant NE and AVP infusions for the treatment of septic shock.
  
  
  METHODS
  Consecutive patients receiving concomitant NE and AVP infusions for septic shock admitted to the intensive care units of a tertiary care academic medical center were evaluated.
  
  
  RESULTS
  Of 50 included patients, the first vasoactive medication discontinued was NE in 32 patients and AVP in 18 patients. The groups had similar Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores at shock onset and at the time of discontinuation of the first agent. Five patients who had NE discontinued first (16%) versus 10 patients who had AVP discontinued first (56%) developed hypotension within 24 hours (unadjusted relative risk, 3.6; 95% confidence interval, 1.5-4.5; P = .008). In a multivariate analysis, only discontinuation of AVP first was independently associated with hypotension (adjusted relative risk, 5.9; 95% confidence interval, 1.7-21.0; P = .006).
  
  
  CONCLUSIONS
  Discontinuation of AVP before NE may lead to a higher incidence of hypotension in patients recovering from septic shock receiving concomitant AVP and NE.
authors.affiliation: Department of Pharmacy, Cleveland Clinic, Cleveland, OH 44195, USA. bauers@ccf.org
authors.forename: Seth R
authors.initials: SR
authors.lastname: Bauer
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Aloi
authors.forename: Christine L
authors.initials: CL
authors.lastname: Ahrens
authors.forename: Jun-Yen
authors.initials: JY
authors.lastname: Yeh
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Culver
authors.forename: Anita J
authors.initials: AJ
authors.lastname: Reddy
mesh_terms: D018806:APACHE; D015331:Cohort Studies; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D007022:Hypotension / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D015994:Incidence; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009638:Norepinephrine / Q000008:administration & dosage*; D012189:Retrospective Studies; D012772:Shock, Septic / Q000150:complications / Q000188:drug therapy*; D016896:Treatment Outcome; D014667:Vasopressins / Q000008:administration & dosage*
chemical_list: D014667:Vasopressins; D009638:Norepinephrine