Variation in Fluid and Vasopressor Use in Shock With and Without Physiologic Assessment: A Multicenter Observational Study

• Type of Material: Article
• Authors: Jen-Ting Chen, Montefiore Medical Center; Russel Roberts, Massachusetts General Hospital; Melissa J Fazzari, Albert Einstein College of Medicine; Kianoush Kashani, Mayo Clinic; Nida Qadir, University of California Los Angeles; Charles B Cairns, University of Arizona; Kusum Mathews, Mount Sinai Health System, New York, NY.; Pauline Park, University of Michigan; Akram Khan, Oregon Health and Science University, Portland, OR.; James F Gilmore, Brigham and Women’s Hospital, Boston, MA.; Anne Rain T Brown, Univ Texas MD Anderson Canc Ctr; Betty Tsuei, University of Cincinnati; Michele Handzel, University of Rochester; Alfredo Lee Chang, University of Southern California; Abhijit Duggal, Cleveland Clinic; Michael Lanspa, InterMt Healthcare; James Taylor Herbert, Duke University; Anthony Martinez, St Agnes Hospital, Baltimore, MD.; Joseph Tonna, University of Utah Health; Mahmoud A Ammar, Yale-New Haven Health, New Haven, CT.; Drayton Hammond, Rush University; Lama H Nazer, King Hussein Cancer Center, Amman, Jordan.; Mojdeh Heavner, University of Maryland Medical Center; Erin Pender, UMKC Truman Medical Centers, Kansas City, MO.; Lauren Chambers, Vidant Medical Center, Greenville, NC.; Michael T Kenes, Wake Forest Baptist Health; David Kaufman, New York University; April Downey, Ohio Health Riverside Methodist Hospital, Columbus, OH.; Brent Brown, University of Oklahoma Health Sciences Center; Darlene Chaykosky, Geisinger Wyoming Valley Medical Center; Armand Wolff, Bridgeport Hospital; Michael Smith, Lake Region General Healthcare, Laconia, NH.; Katie Nault, Lahey Hospital & Medical Center; Jonathan Sevransky, Emory University; Michelle N Gong, Montefiore Medical Center
• Language: English
• Date: 2020-10-01
• Publisher: LIPPINCOTT WILLIAMS & WILKINS
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2020 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
• Final Published Version (URL): http://dx.doi.org/10.1097/CCM.0000000000004429
• Title of Journal or Parent Work: CRITICAL CARE MEDICINE
• Volume: 48
• Issue: 10
• Start Page: 1436
• End Page: 1444
• Keywords: NOREPINEPHRINE; SEVERE SEPSIS; RESPONSIVENESS; GOAL-DIRECTED THERAPY; mortality; resuscitation; hemodynamic monitor; VOLUME EXPANSION; fluid; SEPTIC SHOCK; MANAGEMENT; General & Internal Medicine; vasopressor; shock; INTENSIVE-CARE; Critical Care Medicine; Science & Technology; Life Sciences & Biomedicine

Abstract

Objectives: To characterize the association between the use of physiologic assessment (central venous pressure, pulmonary artery occlusion pressure, stroke volume variation, pulse pressure variation, passive leg raise test, and critical care ultrasound) with fluid and vasopressor administration 24 hours after shock onset and with in-hospital mortality. Design: Multicenter prospective cohort study between September 2017 and February 2018. Settings: Thirty-four hospitals in the United States and Jordan. Patients: Consecutive adult patients requiring admission to the ICU with systolic blood pressure less than or equal to 90 mm Hg, mean arterial blood pressure less than or equal to 65 mm Hg, or need for vasopressor. Interventions: None. Measurement and Main Results: Of 1,639 patients enrolled, 39% had physiologic assessments. Use of physiologic assessment was not associated with cumulative fluid administered within 24 hours of shock onset, after accounting for baseline characteristics, etiology and location of shock, ICU types, Acute Physiology and Chronic Health Evaluation III, and hospital (beta coefficient, 0.04; 95% CI, -0.07 to 0.15). In multivariate analysis, the use of physiologic assessment was associated with a higher likelihood of vasopressor use (adjusted odds ratio, 1.98; 95% CI, 1.45-2.71) and higher 24-hour cumulative vasopressor dosing as norepinephrine equivalent (beta coefficient, 0.37; 95% CI, 0.19-0.55). The use of vasopressor was associated with increased odds of in-hospital mortality (adjusted odds ratio, 1.88; 95% CI, 1.27-2.78). In-hospital mortality was not associated with the use of physiologic assessment (adjusted odds ratio, 0.86; 95% CI, 0.63-1.18). Conclusions: The use of physiologic assessment in the 24 hours after shock onset is associated with increased use of vasopressor but not with fluid administration.