815: TIME TO HEMODYNAMIC STABILITY AFTER IMPLEMENTATION OF A NOREPINEPHRINE RAPID TITRATION PROTOCOL

Abstract

Introduction: Norepinephrine (NE) is the primary vasoactive medication for many different shock states and is titrated to have a hemodynamic effect. A rapid titration protocol was recently implemented at our institution to provide nurses the ability to quickly titrate NE and comply with Joint Commission regulations. The purpose of this study is to evaluate whether implementing a rapid titration protocol for NE impacted time to hemodynamic stability in critically ill patients. Methods: A single-center, retrospective study of adult ICU patients receiving NE as a first line agent at a large academic medical center was performed. The patients were categorized into the pre-implementation group with standard titration instructions from April 2022 and the post implementation group with the rapid titration instructions from July 2022. Our primary outcome was to evaluate the time to hemodynamic stability based on mean arterial pressure (MAP) goals. Secondary outcomes included ICU and hospital length of stay (LOS), all-cause mortality and safety outcomes with NE administration. Results: A total of 64 patients were included in our analysis, of which, 30 patients were included in the pre-implementation group and 34 in the post-implementation group. Baseline characteristics were similar in both the groups, including NE starting rate (0.07 mcg/kg/min vs 0.08 mcg/kg/min, p=0.9), and Modified Early Warning Score (5 vs. 4, p=0.07). The primary outcome of time to hemodynamic stability based on MAP did not differ between the groups (median 12.5 minutes [IQR 0-28] vs. 11.5 minutes [IQR 0-36], p=0.7). However, the rapid titration group received significantly less concomitant IV vasopressors in the first 24 hours (50% vs. 18%, p=0.006) and experienced longer time to second vasopressor initiation (median 2.5 hours [IQR 0.10-3.6] vs. 10 hours [IQR 2.5-20]). Conclusions: At our institution, rapid titration instructions for NE did not shorten time to hemodynamic stability compared to the standard titration protocol. Our study shows that utilizing the NE rapid titration protocol may be safe and may reduce the need for an additional vasopressor. Further prospective studies are warranted to assess compliance with implementing a rapid titration protocol and its potential benefits.