(1643) Evaluation of Vasopressor De-Escalation Strategies in Medical ICU Patients With Septic Shock

Introduction: While guidelines recommend norepinephrine (NE) followed by vasopressin (AVP) for hypotension in septic shock, there is no recommended order for discontinuing vasopressors. Previous studies evaluating order of vasopressor discontinuation in patients with septic shock showed variable rates of hypotension. The purpose of this study was to evaluate the impact of the order of vasopressor discontinuation on frequency of hypotension among medical intensive care unit (ICU) patients with septic shock.

Methods: This retrospective, multi-center cohort study evaluated medical ICU patients admitted for septic shock who received ≥24 hours of concomitant NE and AVP. Patients were divided into NE discontinued first and AVP discontinued first groups. The primary outcome was a composite of hypotension requiring a fluid or albumin bolus, increased vasopressor dose, or vasopressor initiation within 24 hours of discontinuing first agent. Secondary outcomes included incidence of hypotension composite outcome within 12 hours, time to hypotension, vasopressor duration, ICU and hospital length of stay, and NE and AVP cost. Propensity score matching (PSM) was utilized to ensure balanced treatment groups.

Results: Before PSM, there were 80 patients included (63 in AVP discontinued first and 17 in the NE discontinued first group). After PSM, 15 patients were included in each group. The primary composite outcome of hypotension occurred in 12 patients (80%) when AVP was discontinued first versus 8 patients (53.3%) when NE was discontinued first post-PSM (p=0.245). The incidence of hypotension within 12 hours was reduced in the AVP discontinued first group after PSM (p=0.027). All other outcomes were similar among both groups after PSM.

Conclusions: Discontinuation of AVP prior to NE was associated with a non-significant reduction in rebound hypotension within 24 hours. Larger prospective studies are warranted to validate present findings.