Key Point

The selection, use, and monitoring of vasopressor and inotrope therapy for sepsis and septic shock is highly variable. Following published sepsis guidelines may help to minimize this variability.

SAN FRANCISCO—paragraph goes here

STEM CELLS TESTED

Guidelines exist for the hemodynamic management of sepsis and septic shock with inotropes and vasopressors, but not very many clinicians follow them, suggest the results of a survey presented at the Annual Meeting of the Society of Critical Care Medicine. Among 217 ICU pharmacists in North America, Jaclyn M. LeBlanc, PharmD, and colleagues found that only 13.4% of respondents had hemodynamic management protocols in their ICU.¹

"Our findings are a wake-up call," Dr. LeBlanc, a Critical Care Pharmacy Research Fellow at Ohio State University in Columbus, told Pulmonary Reviews. "The guidelines are out there," she emphasized. "But they need to be applied to patients with sepsis and septic shock."

That would result in greater standardization of care for those patients and much less variability in the selection, dosing, and monitoring of their inotrope and vasopressor therapy, said Joseph F. Dasta, MSc, one of Dr. LeBlanc’s two coauthors. "We saw a low rate of perceived adverse reactions with norepinephrine, which was surprising because that drug is often associated with arrhythmias," noted Mr. Dasta, Professor of Pharmacy at Ohio State University.

Of the pharmacists surveyed, 91.2% were from the United States and 8.8% were from Canada. The types of ICUs that they worked for included general (41.5%), medical (29%), surgical/trauma (18.5%), cardiac (9.6%), and "other" (1.4%).

Respondents reported large variation in inotrope and vasopressor therapy for patients with sepsis and septic shock. Inotropes were used "always" in 5.1% of these patients, "often" in 11.5%, "sometimes" in 47.5%, "rarely" in 34.6%, and "never" in 1.4%. The inotrope chosen to treat these patients was dobutamine in 62.6% of cases, dopamine in 21.4%, milrinone in 7.8%, norepinephrine in 6.3%, and epinephrine in 1.9%.

Vasopressor and/or inotrope "cocktails" consisted of norepinephrine and vasopressin with and without dopamine in 15.3% and 13.4% of cases, respectively. Norepinephrine and vasopressin were combined with dobutamine in 9.3% of patients who received a vasopressor/inotrope combination.

Concentrations and dosages of the agents studied also varied greatly. Standard and maximum dopamine concentrations, for example, ranged from 0.0064 to 4.0 mg/mL and from 0.0064 to 3,200 mg/mL, respectively. Maximum dopamine dosages ranged from 10 to 40 µg/kg/min.

The survey responses showed that vasopressin was administered by constant infusion at 0.04 U/min in 51.7% of cases. It was titrated up to a maximum dose of 0.04 or 0.1 U/min in 24.6% and 9% of cases, respectively.

Of the respondents, 39.5% indicated that their ICU used a mean arterial pressure of greater than 60 mm Hg to guide vasopressor titration, while 18.1% reported that a mean arterial pressure of greater than 70 mm Hg was used for that purpose; 20.9% said that their ICU based vasopressor titration on the mean arterial and systolic blood pressures.

The usage rates of parameters often cited to support the decision to add inotropes to sepsis/septic shock therapy were as follows: urine output, 16.1%; clinical signs, 23.5%; hypotension, 25.8%; oxygen saturation or oxygen delivery, 36.9%; and cardiac index, 68.7%.

—Timothy Begany

Reference
1. LeBlanc JM, Dasta JF, Hollenberg SM. National survey of vasopressors and inotropes in sepsis and septic shock. Presented at: annual meeting of the Society of Critical Care Medicine; January 10, 2006; San Francisco, Calif.

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