title: Intensity of Vasopressor Therapy for Septic Shock and the Risk of In-Hospital Death.
abstract: Given the high mortality of 30%-60% associated with septic shock, distinguishing which patients do or do not have a reasonable chance of surviving with aggressive treatment could help clinicians and families make informed decisions.
  
  
  
  To determine if intensity of vasopressor therapy accurately predicts in-hospital death.
  
  
  
  This observational cohort study analyzed in-hospital mortality as a function of intensity of vasopressor therapy in a consecutive series of adults with septic shock treated over a four-year period. Receiver operating characteristic curve analysis assessed the overall strength of the intensity-mortality relationship.
  
  
  
  A total of 808 patients with septic shock experienced an in-hospital death rate of 41.0% (331/808; 95% CI, 38.5%-44.5%). The greater the peak number of vasopressors required, the higher the death rate, which reached 92.3% (12/13; 95% CI, 79.4%-100.0%) when three different pressors were being infused at full dose. The receiver operating characteristic curve analysis revealed that number of simultaneous vasopressors and vasopressor dose load performed equally well in predicting death or survival.
  
  
  
  When a standard full dose of a vasopressor fails to normalize blood pressure in a patient with septic shock, escalation begins to yield diminishing returns as the dose and multiplicity of agents approach practical upper limits. Although it is not possible to specify a precise cutoff for limiting vs. intensifying therapy, a mortality of 80% or higher-characterized by two or more concurrent vasopressors at full dose-should prompt shared decision making with the patient's family.
authors.affiliation: Office of Health Outcomes Research, Winthrop University Hospital, Mineola, New York, USA; School of Medicine, Stony Brook University, Stony Brook, New York, USA. Electronic address: dbrand@winthrop.org.
authors.forename: Donald A
authors.initials: DA
authors.lastname: Brand
authors.affiliation: Westchester Institute for Human Development, Valhalla, New York, USA; School of Health Sciences and Practice, New York Medical College, Valhalla, New York, USA.
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Patrick
authors.affiliation: School of Medicine, Stony Brook University, Stony Brook, New York, USA; Palliative Medicine and Bioethics, Department of Medicine, Winthrop University Hospital, Mineola, New York, USA.
authors.forename: Jeffrey T
authors.initials: JT
authors.lastname: Berger
authors.affiliation: School of Medicine, Stony Brook University, Stony Brook, New York, USA; Pulmonary and Critical Care Medicine, Winthrop University Hospital, Mineola, New York, USA.
authors.forename: Mediha
authors.initials: M
authors.lastname: Ibrahim
authors.affiliation: School of Medicine, Stony Brook University, Stony Brook, New York, USA; Pulmonary and Critical Care Medicine, Winthrop University Hospital, Mineola, New York, USA.
authors.forename: Ajsza
authors.initials: A
authors.lastname: Matela
authors.affiliation: Pulmonary Associates of Bristol, Bristol, Connecticut, USA.
authors.forename: Shweta
authors.initials: S
authors.lastname: Upadhyay
authors.affiliation: School of Medicine, Stony Brook University, Stony Brook, New York, USA; Pulmonary and Critical Care Medicine, Winthrop University Hospital, Mineola, New York, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Spiegler
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015984:Causality; D015331:Cohort Studies; D015897:Comorbidity; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007022:Hypotension / Q000188:drug therapy* / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D009518:New York / Q000453:epidemiology; D015995:Prevalence; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D012772:Shock, Septic / Q000188:drug therapy* / Q000401:mortality*; D015996:Survival Rate; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000008:administration & dosage*; D055815:Young Adult
chemical_list: D014662:Vasoconstrictor Agents
keywords: Vasoconstrictor agents; cohort studies; critical care; decision making; hospital mortality; septic shock