Survival after shock requiring high-dose vasopressor therapy.
BACKGROUND
Some patients with hypotensive shock do not respond to usual doses of vasopressor therapy. Very little is known about outcomes after high-dose vasopressor therapy (HDV). We sought to characterize survival among patients with shock requiring HDV. We also evaluated the possible utility of stress-dose corticosteroid therapy in these patients.


METHODS
We conducted a retrospective study of patients with shock requiring HDV in the ICUs of five hospitals from 2005 through 2010. We defined HDV as receipt at any point of ≥ 1 μg/kg/min of norepinephrine equivalent (calculated by summing norepinephrine-equivalent infusion rates of all vasopressors). We report survival 90 days after hospital admission. We evaluated receipt of stress-dose corticosteroids, cause of shock, receipt of CPR, and withdrawal or withholding of life support therapy.


RESULTS
We identified 443 patients meeting inclusion criteria. Seventy-six (17%) survived. Survival was similar (20%) among the 241 patients with septic shock. Among the 367 nonsurvivors, 254 (69%) experienced withholding/withdrawal of care, and 115 (31%) underwent CPR. Stress-dose corticosteroid therapy was associated with increased survival (P = .01).


CONCLUSIONS
One in six patients with shock survived to 90 days after HDV. The majority of nonsurvivors died after withdrawal or withholding of life support therapy. A minority of patients underwent CPR. Additionally, stress-dose corticosteroid therapy appears reasonable in patients with shock requiring HDV.
Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT.
Samuel M
SM
Brown
Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT.
Michael J
MJ
Lanspa
Research and Evaluation, Kaiser-Permanente Southern California, Pasadena, CA.
Jason P
JP
Jones
Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Homer Warner Center for Informatics Research, Intermountain Medical Center, Murray, UT.
Kathryn G
KG
Kuttler
Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT.
Yao
Y
Li
Department of Pharmacy, Intermountain Medical Center, Murray, UT.
Rick
R
Carlson
Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT.
Russell R
RR
Miller
Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT; Division of Pediatric Critical Care, University of Utah School of Medicine, Salt Lake City, UT.
Eliotte L
EL
Hirshberg
Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT.
Colin K
CK
Grissom
Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT.
Alan H
AH
Morris
D018806:APACHE; D000328:Adult; D016887:Cardiopulmonary Resuscitation; D006801:Humans; D008020:Life Support Care; D008875:Middle Aged; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012769:Shock / Q000188:drug therapy* / Q000401:mortality*; D014662:Vasoconstrictor Agents / Q000008:administration & dosage*
D014662:Vasoconstrictor Agents