title: Efficacy and Outcomes After Vasopressin Guideline Implementation in Septic Shock.
abstract: BACKGROUND
  In septic shock, the dose of norepinephrine (NE) at which vasopressin (AVP) should be added is unknown. Following an increase in AVP price, our medical intensive care unit (MICU) revised its vasopressor guidelines to reserve AVP for patients requiring greater than 50 µg/min of NE.
  
  
  OBJECTIVE
  The purpose of this study is to compare efficacy and safety outcomes for patients admitted before the guideline revision with those for patients admitted after the revision.
  
  
  METHODS
  This was a single-center, retrospective cohort study of patients admitted to Vanderbilt University Medical Center from November 1, 2014, to November 30, 2015. Before June 1, 2015, the vasopressor guidelines recommended initiation of AVP for patients requiring 10 µg/min of NE or greater. After June 1, 2015, the guidelines recommended initiation of AVP at a NE dose of 50 µg/min or greater.
  
  
  RESULTS
  Time to achieve goal mean arterial pressure (MAP) was shorter in the postintervention group (2.0 vs 1.3 hours; P = 0.03) in univariate analysis but not after adjusting for prespecified confounders. Incidence of new arrhythmias was similar between the 2 groups (14.9% vs 10.9%; P = 0.567). In multivariable analysis accounting for baseline severity of illness, admission after the revision was associated with decreased 28-day mortality (odds ratio = 0.34; 95% CI = 0.16-0.71; P = 0.004).
  
  
  CONCLUSIONS
  Use of a vasopressor guideline restricting AVP initiation in septic patients to those on at least 50 µg/min of NE appeared to be safe and did not affect the time to reach goal MAP.
authors.affiliation: 1 Vanderbilt University Medical Center, Nashville, TN, USA.
authors.forename: Janet Y
authors.initials: JY
authors.lastname: Wu
authors.affiliation: 1 Vanderbilt University Medical Center, Nashville, TN, USA.
authors.forename: Joanna L
authors.initials: JL
authors.lastname: Stollings
authors.affiliation: 2 Vanderbilt University School of Medicine, Nashville, TN, USA.
authors.forename: Arthur P
authors.initials: AP
authors.lastname: Wheeler
authors.affiliation: 2 Vanderbilt University School of Medicine, Nashville, TN, USA.
authors.forename: Matthew W
authors.initials: MW
authors.lastname: Semler
authors.affiliation: 2 Vanderbilt University School of Medicine, Nashville, TN, USA.
authors.forename: Todd W
authors.initials: TW
authors.lastname: Rice
mesh_terms: D000368:Aged; D001145:Arrhythmias, Cardiac / Q000453:epidemiology / Q000209:etiology; D062186:Arterial Pressure / Q000187:drug effects*; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D015994:Incidence; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D009638:Norepinephrine / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D017410:Practice Guidelines as Topic / Q000592:standards*; D012189:Retrospective Studies; D012772:Shock, Septic / Q000188:drug therapy* / Q000503:physiopathology; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D014667:Vasopressins / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use
chemical_list: D014662:Vasoconstrictor Agents; D014667:Vasopressins; D009638:Norepinephrine
keywords: adrenergic agonists; clinical research; critical care; sepsis; sympathomimetics