Prognosis of patients with shock receiving vasopressors

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BACKGROUND： Consensus guidelines suggested that both dopamine and norepinephrine may be used， but specific doses are not recommended. The aim of this study is to determine the predictive role of vasopressors in patients with shock in intensive care unit.

METHODS： One hundred and twenty-two patients， who had received vasopressors for 1 hour or more in intensive care unit （ICU） between October 2008 and October 2011， were included.There were 85 men and 37 women， with a median age of 65 years （55–73 years）. Their clinical data were retrospectively collected and analyzed.

RESULTS： The median simplified acute physiological score 3 （SAPS 3） was 50 （42–55）. Multivariate analysis showed that septic shock （P=0.018， relative risk： 4.094； 95% confidential interval： 1.274–13.156）， SAPS 3 score at ICU admission （P=0.028， relative risk： 1.079； 95% confidential interval： 1.008–1.155）， and norepinephrine administration （P

CONCLUSION： Septic shock， SAPS 3 score at ICU admission， and norepinephrine administration were independent predictors of ICU death for patients with shock. Patients who received norepinephrine ≥0.7 μg/kg per minute had an increased ICU mortality， an increased in-hospital mortality， and a decreased 510-day survival rate.

KEY WORDS： Vasopressors； Intensive care； Shock

World J Emerg Med 2013；4（1）：59–62

DOI： 10.5847/ wjem.j.1920–8642.2013.01.011

INTRODUCTION

Critically ill patients with shock had a mortality of 27.5% to 50.2%.[1–3] In addition to sufficient volume resustitation， vasopressors are frequently used to restore tissue perfusion. A multicenter randomized study[3] revealed that there is no significant difference in patients with shock who are treated with dopamine or norepinephrine. Dopamine administration is associated with greater arrhythmic events. Hence， norepinephrine administration is preferred to dopamine administration. Povoa et al[4] found that norepinephrine administration could be associated with worse outcomes in patients with septic shock. On the other hand， there is no consensus on the maximal dose of vasopressors. Consensus guidelines suggested that both dopamine and norepinephrine may be used， but not recommended on specific doses.[5] Recently， Benbenishty et al[2] found that patients with shock who received norepinephrine or epinephrine more than 0.5 μg/kg per minute showed 96% likelihood of intensive care unit （ICU） death. The purpose of this study was to determine the predictive role of vasopressors and maximal dosage of vasopressors in patients with shock in ICU.

METHODS

This retrospective study was conducted at the department of ICU of Cancer Hospital （Institute）， the Chinese Academy of Medical Sciences and Peking Union Medical College in Beijing， China. The ICU is a 10-bed medical-surgical unit. Informed consent was obtained because of the observational nature of the study. One hundred and twenty-two patients who had received vasopressors between October 2008 and October 2011 were included in this study. There were 85 men and 37 women， with a median age of 65 years （55–73 years）. The median SAPS 3 score of the patients was 50 （42–55）.

The following clinical data were retrospectively analyzed： age， gender， simplified acute physiological score 3 （SAPS） on day of ICU admission，[6] type of vasopressors （dopamine or norepinephrine）， maximal dosage of vasopressors， duration of infusion， laboratory values （white blood cell count， ratio of PaO2 to FiO2， serum total bilirubin， serum creatinine level， platelet count） on the day of admission， cause of shock， mechanical ventilation treatment， duration of mechanical ventilation， length of ICU stay， ICU mortality， length of hospitalization， and in-hospital mortality. Shock was defined as mean blood pressure being less than 65 mmHg despite an adequate amount of fluids （at least 1000 mL of crystalloids or 500 mL of colloids） had been administered.

Patients who were younger than 18 years of age were excluded.

Statistical analysis

The SPSS software package 16.0 for Windows was used for statistical analysis. Data were presented as median （interquartile range） for continuous variables， and percentages for dichotomous variables. Continuous variables were analyzed using Student's t test， and categorical variables were analyzed using the Chi-square test. Univariate or multivariate Cox regression was used to define the predictors of ICU mortality. The area under the receiver operating characteristic curve （AUROC） was used to ascertain the dosage of vasopressors that determine patients who died in ICU or not. Survivals were estimated using the Kaplan-Meier method， and the log-rank test was used to analyze differences between curves. A P value less than 0.05 was considered statistically significant.

RESULTS

In the 122 patients with shock， dopamine was the most commonly used vasopressor （94.3%）. It was used as a single agent in 73 patients. Norepinephrine was used in 49 patients， and it was used as a single agent in 7 patients. Forty-two patients received both dopamine and nonepinephrine. The median concentration of dopamine was 10 （6–16） μg/kg per minute and the median concentration of nonepinephrine was 1.3 （0.5–2.1） μg/kg per minute.

Twenty-nine patients died in ICU. Sixteen patients died from septic shock， 11 patients died from gastrointestinal bleeding， and 2 patients died from myocardial infarction. Other characteristics of the patients are shown in Table 1.

Univariate analysis showed that cause of shock， SAPS 3 score at ICU admission， mechanical ventilation treatment， and norepinephrine administration were predictive factors of ICU death （Table 1）. Multivariate analysis showed that septic shock， SAPS 3 score at ICU admission， and norepinephrine administration were independent predictors of ICU death （Table 2）.

The results of receiver operating characteristic curve analysis are shown in Figure 1. Administration of norepinephrine ≥0.7 μg/kg per minute resulted in a sensitivity of 75.9% and a specificity of 90.3% for the likelihood of ICU death， with area under the curve of 0.844±0.048 （P

Compared with patients receiving norepinephrine

DISCUSSION

Our data suggested that septic shock， SAPS 3 score at ICU admission， and norepinephrine administration were independent predictors of ICU death for patients with shock. Patients who received norepinephrine ≥0.7 μg/kg per minute were more likely to have ICU death and in-hospital death than those who received norepinephrine

Norepinephrine administration was predictive of ICU death in patients with shock. Póvoa et al[4] reported that norepinephrine administration was associated with worst outcomes in patients with septic shock， with a 3.5 increase of the 28-day mortality risk. After adjusting for SAPS II， norepinephrine administration was still significantly associated with an increased death rate. In this study， after adjusting for SAPS 3， norepinephrine administration was associated with a 9.353 increase of ICU mortality risk in patients with shock. However， controversy exists regarding the maximal dosage of norepinephrine predictive of death. Benbenishty et al[2] reported that patients receiving norepinephrine or epinephrine ≥0.5 μg/kg per minute had a 96% possibility of death in a cohort with shock receiving vasopressors. Sakr et al[1] found that in 1058 patients with shock due to any cause， the median dosage of norepinephrine in non-survivors （n= 405） was 0.7 μg/kg per minute， which was significantly higher than 0.5 μg/kg per minute in survivors （n=653）. Póvoa et al[4] reported that norepinephrine administration was associated with worst outcome in patients with septic shock； however， the maximal dosage of norepinephrine was not mentioned in their study. In our study， the patients who received norepinephrine ≥0.7 μg/kg per minute showed a sensitivity of 75.9% and a specificity of 90.3% for the likelihood of ICU death， and these patients had a poor 510-day survival rate compared with those receiving norepinephrine

Our study has several limitations. First， this study is retrospective. Second， the sample of this study is relatively small. Third， our results were obtained from a single medical center and may not be generalized to other medical centers.

In conclusion， in this study， septic shock， SAPS 3 score at admission and norepinephrine administration were independent predictors of ICU death for patients with shock. Patients who received norepinephrine ≥0.7 μg/kg per minute had an increased ICU mortality， an increased in-hospital mortality， and a decreased 510-day survival rate compared with patients who received norepinephrine

Funding： None.

Ethical approval： Not needed.

Conflicts of interest： No competing interests.

Contributors： Xing XZ and Sun KL designed the research. Xing XZ analyzed the data， and wrote the paper. All authors read and approved the final version.

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Received August 25， 2012

Accepted after revision December 21， 2012