Efficacy and Outcomes After Vasopressin Guideline Implementation in Septic Shock

2016 ◽  
Vol 51 (1) ◽  
pp. 13-20 ◽  
Author(s):  
Janet Y. Wu ◽  
Joanna L. Stollings ◽  
Arthur P. Wheeler ◽  
Matthew W. Semler ◽  
Todd W. Rice
Keyword(s):  
Septic Shock ◽  
Medical Intensive Care Unit ◽  
Medical Center ◽  
Guideline Implementation ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Severity Of Illness ◽  
Medical Intensive Care ◽  
Vanderbilt University ◽  
Goal Map

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.

Comparison of Vasopressor Duration in Septic Shock Patients With and Without Cirrhosis

2020 ◽  
pp. 106002802098072
Author(s):  
Melissa M. Durst ◽  
Elizabeth A. Eitzen ◽  
Scott T. Benken
Keyword(s):  
Septic Shock ◽  
Hospital Mortality ◽  
Medical Center ◽  
Cohort Analysis ◽  
Academic Medical Center ◽  
Treatment Strategies ◽  
Severity Of Illness ◽  
Discharge Disposition ◽  
Increase Risk ◽  
Vasopressor Use

Background Patients with cirrhosis have immune dysfunction, altered inflammatory response, and hemodynamic changes which increase risk of septic shock and potentially prolong management with fluids, vasopressors, and other therapies. Due to limited available guidance, this study aimed to characterize vasopressor use in patients with cirrhosis in relation to patients without cirrhosis in septic shock. Methods This was a retrospective matched cohort analysis of 122 patients admitted to the intensive care unit (ICU) at an academic medical center from January 2015 to November 2017. Patients were grouped based on the presence or absence of cirrhosis and matched based on severity of illness scoring. The primary outcome was vasopressor duration. Secondary comparisons included total vasopressor requirement, length of hospital and ICU stay, in-hospital mortality, change in organ function, and discharge disposition. Results The group with cirrhosis had significantly longer median (interquartile range [IQR]) durations of vasopressor therapy compared with the group without cirrhosis (86.0 [42.0-164.5] vs 39.0 [14.5-82.0] hours; P = 0.003) leading to increased median (IQR) vasopressor exposure (71.7 [15.5-239.5] vs 24.7 [5.3-77.9] mg norepinephrine [NE] equivalents; P = 0.003). No difference was found in in-hospital mortality between groups. However, regression analysis showed vasopressor exposure was associated with in-hospital mortality. Conclusion and Relevance Patients with cirrhosis in septic shock have increased vasopressor durations and overall requirements compared with patients without cirrhosis. Increased durations and requirements is associated with poorer outcomes independent of presence of cirrhosis. Future studies are needed to improve vasopressor treatment strategies and end points utilized in cirrhosis.

Hemodynamic Response to Vasopressin Dosage of 0.03 Units/Min vs. 0.04 Units/Min in Patients With Septic Shock

2020 ◽  
pp. 088506662097718 ◽  
Author(s):  
Seth R. Bauer ◽  
Gretchen L. Sacha ◽  
Simon W. Lam ◽  
Lu Wang ◽  
Anita J. Reddy ◽  
...  
Keyword(s):  
Septic Shock ◽  
Primary Outcome ◽  
Medical Center ◽  
Academic Medical Center ◽  
Initial Dosage ◽  
Hemodynamic Response ◽  
Adjusted Relative Risk ◽  
Covariate Balance ◽  
Academic Medical ◽  
Medical Intensive Care

Background: Arginine vasopressin (AVP) is suggested as an adjunct to norepinephrine in patients with septic shock. Guidelines recommend an AVP dosage up to 0.03 units/min, but 0.04 units/min is commonly used in practice based on initial studies. This study was designed to compare the incidence of hemodynamic response between initial fixed-dosage AVP 0.03 units/min and AVP 0.04 units/min. Methods: This retrospective, multi-hospital health system, cohort study included adult patients with septic shock receiving AVP as an adjunct to catecholamine vasopressors. Patients were excluded if they received an initial dosage other than 0.03 units/min or 0.04 units/min, or AVP was titrated within the first 6 hours of therapy. The primary outcome was hemodynamic response, defined as a mean arterial pressure ≥65 mm Hg and a decrease in catecholamine dosage at 6 hours after AVP initiation. Inverse probability of treatment weighting (IPTW) based on the propensity score for initial AVP dosage receipt was utilized to estimate adjusted exposure effects. Results: Of the 1536 patients included in the observed data, there was a nearly even split between initial AVP dosage of 0.03 units/min (n = 842 [54.8%]) and 0.04 units/min (n = 694 [45.2%]). Observed patients receiving AVP 0.03 units/min were more frequently treated at the main campus academic medical center (96.3% vs. 52.2%, p < 0.01) and in a medical intensive care unit (87.4% vs. 39.8%, p < 0.01). The IPTW analysis included 1379 patients with achievement of baseline covariate balance. There was no evidence for a difference between groups in the incidence of hemodynamic response (0.03 units/min 50.0% vs. 0.04 units/min 53.1%, adjusted relative risk 1.06 [95% CI 0.94, 1.20]). Conclusions: Initial AVP dosing varied by hospital and unit type. Although commonly used, an initial AVP dosage of 0.04 units/min was not associated with a higher incidence of early hemodynamic response to AVP in patients with septic shock.

A Prediction Rule For Mortality in the Medical Intensive Care Unit Based on Early Acute Organ-System Failure

1994 ◽  
Vol 9 (4) ◽  
pp. 172-178 ◽  
Author(s):  
Victor Gordan ◽  
Roger K. Pitman ◽  
Thérese A. Stukel ◽  
Daniel Teres ◽  
Edward Gillie
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Medical Intensive Care Unit ◽  
Medical Center ◽  
Prediction Rule ◽  
Organ System ◽  
System Failure ◽  
Classification Rate ◽  
Organ System Failure ◽  
Medical Intensive Care

We evaluated early acute organ-system failure (AOSF) as a predictor of mortality in medical intensive care unit (MICU) patients. Prospective data were obtained on 825 men admitted to a Veterans Administraion (VA) Medical Center MICU. Clinical criteria were used to diagnose the presence of 7 types of AOSF. Of the 2,364 AOSFs detected, 1,847 (78%) were “early” (i.e., detected within the first 48 hours of MICU stay). A random sample of 550 patients was selected for derivation of a prediction rule for MICU mortality based on age and number of early AOSFs. For each additional early AOSF, the adjusted odds of mortality increased by 3.3 (95% confidence interval: 2.7, 4.0; p < 0.0001). When applied to the cross-validation sample of 275 patients, this rule yielded a sensitivity of 77%, a specificity of 86%, and an overall correct classification rate of 82%. These results suggest that a simple rule based on number of AOSFs detected in the early portion of a patient's MICU stay may be a useful predictor of mortality.

scholarly journals Mortality-associated factors in old patients with severe sepsis or septic shock in the medical intensive care unit

Critical Care ◽  
2007 ◽  
Vol 11 (Suppl 3) ◽  
pp. P29
Author(s):  
R Bak ◽  
CS Salomão ◽  
RL Machado ◽  
GMM Oliveira ◽  
EB Lameu ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Septic Shock ◽  
Severe Sepsis ◽  
Intensive Care ◽  
Associated Factors ◽  
Medical Intensive Care Unit ◽  
Old Patients ◽  
Medical Intensive Care

scholarly journals Changes in perfusion can detect changes in the cardiac index in patients with septic shock

2020 ◽  
Vol 48 (8) ◽  
pp. 030006052093167
Author(s):  
Hui Lian ◽  
Xiaoting Wang ◽  
Qing Zhang ◽  
Hongmin Zhang ◽  
Dawei Liu
Keyword(s):  
Septic Shock ◽  
Cardiac Index ◽  
Characteristic Curve ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Area Under The Curve ◽  
Treatment Phase ◽  
Cardiac Output Monitoring ◽  
Fluid Loading ◽  
Output Monitoring

Objective The perfusion index (PI) is usually used to assess peripheral perfusion, which can be influenced by the cardiac index (CI). CI monitoring is often needed during the treatment of patients with shock. We investigated the relationship between changes in the PI (ΔPI) and changes in the CI (ΔCI) in patients with septic shock. Methods This retrospective study included patients with septic shock who underwent pulse-induced continuous cardiac output monitoring. We measured the CI and PI before and after fluid loading during the first 6 hours of intensive care unit admission. Fluid responsiveness was defined as a ≥10% ΔCI after fluid loading. Other hemodynamic and oxygen-derived parameters were also collected at the exact time of each CI measurement. Results Fifty-five patients were included in the study (29 fluid responders, 26 fluid non-responders). In the univariate analysis, ΔPI was positively correlated with ΔCI. In the multivariable analysis, ΔPI was independently associated with ΔCI. The receiver operating characteristic curve showed that ΔPI was an appropriate marker with which to discriminate a CI increase with an area under the curve of 0.776. Conclusion This study showed a positive correlation between ΔPI and ΔCI during the early treatment phase of septic shock.

Development and Implementation of a Multicomponent Protocol to Promote Sleep and Reduce Delirium in a Medical Intensive Care Unit

2021 ◽  
pp. 106002802110432
Author(s):  
Adrienne Darby ◽  
Kalynn Northam ◽  
C. Adrian Austin ◽  
Lydia Chang ◽  
Stacy Campbell-Bright
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Hospital Mortality ◽  
Medical Intensive Care Unit ◽  
Severity Of Illness ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Poor Sleep ◽  
Medical Intensive Care ◽  
The Impact

Background: Evidence suggests that poor sleep increases risk of delirium. Because delirium is associated with poor outcomes, institutions have developed protocols to improve sleep in critically ill patients. Objective: To assess the impact of implementing a multicomponent sleep protocol. Methods: In this prospective, preimplementation and postimplementation evaluation, adult patients admitted to the medical intensive care unit (ICU) over 42 days were included. Outcomes evaluated included median delirium-free days, median Richards-Campbell Sleep Questionnaire (RCSQ) score, median optimal sleep nights, duration of mechanical ventilation (MV), ICU and hospital length of stay (LOS), and in-hospital mortality. Results: The preimplementation group included 78 patients and postimplementation group, 84 patients. There was no difference in median delirium-free days (1 day [interquartile range, IQR, = 0-2.5] vs 1 day [IQR = 0-2]; P = 0.48), median RCSQ score (59.4 [IQR = 43.2-71.6] vs 61.2 [IQR = 49.9-75.5]; P = 0.20), median optimal sleep nights (1 night [IQR = 0-2] vs 1 night [IQR = 0-2]; P = 0.95), and in-hospital mortality (16.7% vs 17.9%, P = 1.00). Duration of MV (8 days [IQR = 4-10] vs 4 days [IQR = 2-7]; P = 0.03) and hospital LOS (13 days [IQR = 7-22.3] vs 8 days [IQR = 6-17]; P = 0.05) were shorter in the postimplementation group, but both were similar between groups after adjusting for age and severity of illness. Conclusions and Relevance: This report demonstrates that implementation of a multicomponent sleep protocol in everyday ICU care is feasible, but limitations exist when evaluating impact on measurable outcomes. Additional evaluations are needed to identify the most meaningful interventions and best practices for quantifying impact on patient outcomes.

Duodenal Perforation Caused Septic Shock: a Rare Case Combined With Coronavirus Disease 2019

2020 ◽  
Author(s):  
Huanhuan Guo ◽  
Jing Hu ◽  
Yunxiang Li ◽  
Wei Xiang ◽  
Quan Gan
Keyword(s):  
Septic Shock ◽  
Medical Intensive Care Unit ◽  
Duodenal Perforation ◽  
Emergency Laparotomy ◽  
Case Presentation ◽  
Risk Pregnancy ◽  
Multidisciplinary Cooperation ◽  
Epidemic Period ◽  
Medical Intensive Care ◽  
Novel Coronavirus

Abstract Background: Duodenal perforation is one of the rarer causes of acute abdomen in pregnancy, which is especially easy to be overlooked during the outbreak of 2019 novel coronavirus (2019-nCoV) after delivery.Case presentation: Here, we report a case of duodenal perforation-induced septic shock with coronavirus disease 2019 (COVID-19), and the patient underwent emergency laparotomy after reporting to the hospital management department under strict protection. Her recovery in postoperative period in Medical Intensive Care Unit (MICU) was uneventful and she was transferred to a designated hospital for treatment of COVID-19 5 days later.Conclusions: The establishment of emergency green channel for maternal health care, and timely and comprehensive multidisciplinary cooperation during the epidemic period, strengthen the standardized management of high-risk pregnancy, and better guarantee the safety of mothers and infants.

scholarly journals Relationship between Chlorhexidine Gluconate Skin Concentration and Microbial Density on the Skin of Critically Ill Patients Bathed Daily with Chlorhexidine Gluconate

2012 ◽  
Vol 33 (9) ◽  
pp. 889-896 ◽  
Author(s):  
Kyle J. Popovich ◽  
Rosie Lyles ◽  
Robert Hayes ◽  
Bala Hota ◽  
William Trick ◽  
...  
Keyword(s):  
Healthcare Workers ◽  
Medical Intensive Care Unit ◽  
Medical Center ◽  
Chlorhexidine Gluconate ◽  
Gram Positive ◽  
Microbial Density ◽  
Medical Intensive Care ◽  
Skin Cleansing ◽  
The Relationship

Objective and Design.Previous work has shown that daily skin cleansing with Chlorhexidine gluconate (CHG) is effective in preventing infection in the medical intensive care unit (MICU). A colorimetric, semiquantitative indicator was used to measure CHG concentration on skin (neck, antecubital fossae, and inguinal areas) of patients bathed daily with CHG during their MICU stay and after discharge from the MICU, when CHG bathing stopped.Patients and Setting.MICU patients at Rush University Medical Center.Methods.CHG concentration on skin was measured and skin sites were cultured quantitatively. The relationship between CHG concentration and microbial density on skin was explored in a mixed-effects model using gram-positive colony-forming unit (CFU) counts.Results.For 20 MICU patients studied (240 measurements), the lowest CHG concentrations (0–18.75 μg/mL) and the highest gram-positive CFU counts were on the neck (median, 1.07 log10CFUs;P= .014). CHG concentration increased postbath and decreased over 24 hours (P< .001). In parallel, median log10CFUs decreased pre- to postbath (0.78 to 0) and then increased over 24 hours to the baseline of 0.78 (P= .001). A CHG concentration above 18.75 μg/mL was associated with decreased gram-positive CFUs (P= .004). In all but 2 instances, CHG was detected on patient skin during the entire interbath (approximately 24-hour) period (18 [90%] of 20 patients). In 11 patients studied after MICU discharge (80 measurements), CHG skin concentrations fell below effective levels after 1–3 days.Conclusion.In MICU patients bathed daily with CHG, CHG concentration was inversely associated with microbial density on skin; residual antimicrobial activity on skin persisted up to 24 hours. Determination of CHG concentration on the skin of patients may be useful in monitoring the adequacy of skin cleansing by healthcare workers.

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