Timing of adjunctive vasopressin initiation for septic shock patients and hospital mortality: A multicentre observational study

Kyle C White; Rahul Costa-Pinto; Anis Chaba; Philippa McIlroy; Siva Senthuran; Stephen Luke; Antony G Attokaran; Peter Garrett; Mahesh Ramanan; Alexis Tabah; Kiran Shekar; Kevin B Laupland; Hayden White; James McCullough; Andrew Udy; Glenn Eastwood; Rinaldo Bellomo; Queensland Critical Care Research Network (QCCRN)

doi:10.1016/j.ccrj.2024.09.002

Timing of adjunctive vasopressin initiation for septic shock patients and hospital mortality: A multicentre observational study

Crit Care Resusc. 2024 Nov 22;26(4):295-302. doi: 10.1016/j.ccrj.2024.09.002. eCollection 2024 Dec.

Authors

Kyle C White^{1

2

3}, Rahul Costa-Pinto^{4

5}, Anis Chaba⁴, Philippa McIlroy⁶, Siva Senthuran^{7

8}, Stephen Luke^{7

9}, Antony G Attokaran^{2

10}, Peter Garrett^{11

12}, Mahesh Ramanan^{2

13

14}, Alexis Tabah^{2

3

15}, Kiran Shekar^{2

3

16}, Kevin B Laupland^{3

17}, Hayden White^{11

18}, James McCullough^{11

19}, Andrew Udy^{20

21}, Glenn Eastwood⁴, Rinaldo Bellomo^{4

5

21

22

23}; Queensland Critical Care Research Network (QCCRN)

Collaborators

Queensland Critical Care Research Network (QCCRN):
Mahesh Ramanan, Prashanti Marella, Patrick Young, Pip McIlroy, Ben Nash, James McCullough, Kerina J Denny, Mandy Tallott, Andrea Marshall, David Moore, Hayden White, Sunil Sane, Aashish Kumar, Lynette Morrison, Pam Dipplesman, Jennifer Taylor, Stephen Luke, Anni Paasilahti, Ray Asimus, Kyle White, Jason Meyer, Rod Hurford, Meg Harward, James Walsham, Neeraj Bhadange, Wayne Stevens, Kevin Plumpton, Sainath Raman, Andrew Barlow, Alexis Tabah, Hamish Pollock, Stuart Baker, Kylie Jacobs, Antony G Attokaran, David Austin, Jacobus Poggenpoel, Josephine Reoch, Kevin B Laupland, Felicity Edwards, Tess Evans, Jayesh Dhanani, Marianne Kirrane, Pierre Clement, Nermin Karamujic, Paula Lister, Vikram Masurkar, Peter Garrett, Lauren Murray, Jane Brailsford, Todd Erbacher, Kiran Shekar, Jayshree Lavana, George Cornmell, Siva Senthuran, Stephen Whebell, Michelle Gatton, Robert Andrews, Sam Keogh

Affiliations

¹ Intensive Care Unit, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Brisbane, QLD, 4102, Australia.
² Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.
³ Queensland University of Technology (QUT), Brisbane, QLD, Australia.
⁴ Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia.
⁵ Department of Critical Care, Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia.
⁶ Intensive Care Unit, Cairns Hospital, Cairns, Queensland, Australia.
⁷ College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.
⁸ Intensive Care Unit, Townsville Hospital, Townsville, Queensland, Australia.
⁹ Intensive Care Services, Mackay Base Hospital, Mackay, Queensland, Australia.
¹⁰ Intensive Care Unit, Rockhampton Hospital, The Range, Queensland, Australia.
¹¹ School of Medicine and Dentistry, Griffith University, Mount Gravatt, Queensland Australia.
¹² Intensive Care Unit, Sunshine Coast University Hospital, Birtinya, Queensland, Australia.
¹³ Intensive Care Unit, Caboolture Hospital, Caboolture, Queensland, Australia.
¹⁴ Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia.
¹⁵ Intensive Care Unit, Redcliffe Hospital, Brisbane, Queensland, Australia.
¹⁶ Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.
¹⁷ Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
¹⁸ Intensive Care Unit, Logan Hospital, Logan, Queensland, Australia.
¹⁹ Intensive Care Unit, Gold Coast University Hospital, Southport, Queensland, Australia.
²⁰ Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
²¹ Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
²² Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia.
²³ Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia.

Abstract

Objective: The optimal timing of vasopressin initiation as an adjunctive vasopressor remains unclear. We aimed to study the association between the timing of vasopressin commencement, pre-specified physiological parameters, and hospital mortality.

Design: We conducted a multicentre, retrospective, observational study.

Setting: Twelve ICUs in Queensland, Australia between January 2015 and December 2021.

Participants: Adult patients with septic shock who received vasopressin as an adjunctive vasopressor within 72 hours of ICU admission.

Main outcome: Hospital mortality.

Results: Overall, 2747 patients fulfilled the inclusion criteria. Of these, 1850 (67%) started vasopressin within six hours of vasopressor therapy start, while 897 (33%) started vasopressin between six hours and 72 hours. APACHE III score, peak lactate, and creatinine were higher in the early start group. Early vasopressin start was independently associated with decreased hospital mortality (aOR = 0.69, 95% CI = 0.57-0.83). Vasopressin infusion start was also associated with an immediate decrease in the noradrenaline-equivalent dose regardless of timing. There was a statistically significant favourable breakpoint at vasopressin start for the course of arterial pH, lactate, heart rate and crystalloid infusion rate (p<0.001).

Conclusions: In patients with septic shock, early adjunctive vasopressin initiation was independently associated with lower hospital mortality. Vasopressin starting at any time was also associated with reduced tachycardia, acidosis, and hyperlactatemia.

Keywords: Critical care; Hypotension; Intensive care unit; Sepsis; Shock; Vasodilation; Vasopressin.