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Second Vasoactive Agent Alternatives in Patients With Septic Shock Refractory to Norepinephrine in the Intensive Care Unit FREE TO VIEW

Isabella Possagnoli, MD; Samantha Lu, BS; Phillip Stokes, BS; Bryant Nguyen, MD
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Loma Linda University, Loma Linda, CA

Chest. 2015;148(4_MeetingAbstracts):186A. doi:10.1378/chest.2279245
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SESSION TITLE: Biomarkers in Severe Sepsis and Septic Shock

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Wednesday, October 28, 2015 at 02:45 PM - 04:15 PM

PURPOSE: When norepinephrine is not sufficient to maintain hemodynamic stability in septic shock patients, another vasoactive agent is required. The choice of which second agent is generally determined based on patient status, comorbidities, and physician preference. In this study, we test the hypothesis that the second vasoactive agent after reaching optimal norepinephrine dose has an effect on outcome.

METHODS: This study was a retrospective chart review of septic shock patients requiring multiple vasoactive agents in the ICU from July 1, 2008 through June 30, 2012. Patients who received norepinephrine within 24 hours of admission and a second agent (dobutamine, dopamine, phenylephrine, or vasopressin) within 48 hours were enrolled. Adjusted logistic regression modeling and survival analysis were performed to determine variables associated with in-hospital mortality.

RESULTS: Amongst 2,640 patients screened, 234 patients were enrolled, age 61±18 years, APACHE IV 98±27, 81.6% mechanically ventilated, and 65.8% in-hospital mortality. Within 96 hours 2.8±1.0 vasopressors were administered. 50, 50, 66 and 68 patients received dobutamine, dopamine, phenylephrine, and vasopressin as the second agent within 48 hours; with in-hospital mortality 40.0, 66.0, 74.2, and 76.5% respectively, p<0.001. After adjusting for age, gender, congestive heart failure, total fluids at 96 hours, transfusion at 96 hours, norepinephrine infusion rate, mechanical ventilation, and lactate, dobutamine showed significant decreased odds ratio (OR) for mortality compared to vasopressin: OR 0.34 (95%CI 0.14-0.84, p=0.04). Dopamine and phenylephrine were not associated with decreased OR for mortality compared to vasopressin. The relative risk of dying was 55.8% lower in patients receiving dobutamine vs. vasopressin, p<0.01. Survival analysis showed a statistically significant difference in survival time by second vasopressor type, p<0.001.

CONCLUSIONS: In this retrospective analysis, dobutamine is associated with decreased mortality compared to other second vasoactive agents in septic shock when norepinephrine is not sufficient. A prospective randomized trial examining the outcome impact of the second vasoactive agent is needed.

CLINICAL IMPLICATIONS: In septic shock patients refractory to norepinephrine, dobutamine may be the preferred second vasoactive agent.

DISCLOSURE: The following authors have nothing to disclose: Isabella Possagnoli, Samantha Lu, Phillip Stokes, Bryant Nguyen

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