Outcomes of Patients With Septic Shock on Multiple Vasoactive Agents

Abstract

SESSION TITLE: ICU Management SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Septic shock carries a high mortality rate despite various advances. Vasoactive agents are used to maintain hemodynamics and enhance tissue perfusion. There is limited data on the efficacy of using multiple vasoactive agents in the management of septic shock. METHODS: This is a retrospective cohort study of patients from 04/01/2014 to 12/31/2016 who were identified to have septic shock based on ICD-9/10 codes. Inclusion criteria were age≥18, ICU admission, and treatment with ≥1 vasoactive agents (vasopressor or inotrope, including oral agents). Preliminary analysis was performed on 226 subjects using SAS 9.4. Independent t-test and analysis of variance were performed for continuous variables. Chi-squared and Fisher’s exact tests were performed for categorical variables. The primary outcome was 28-day mortality. Secondary outcomes included ICU length of stay (LOS), days on mechanical ventilation (MV), incidence of disseminated intravascular coagulation (DIC) and incidence of arrhythmias. RESULTS: The overall 28-day mortality rate in this cohort was 52.24%. Patients requiring one, two, and three agents had 28-day mortality rates of 41.35%, 62.69%, and 68.09%, respectively (p=0.0010). Significance remained when adjusted for APACHE II scores (p=0.0043). Those patients on two agents were 2.4 times more likely to die at 28-days compared to one agent (OR=2.346, 95% CI 1.202-4.577, p=0.0124). Those on three vasoactive agents were 3.0 times more likely to have mortality at 28-days (OR=2.991, 95% CI 1.434-6.237, p=0.0035). There was no significant difference in mortality between two and three vasoactive agents (OR=1.275, 95% CI=0.577-2.818, p=0.5468). As compared to those on one agent, those on three agents had increased need for hemodialysis (32.7% vs. 8.74%, p=0.0006), longer days on MV (8.42 vs. 3.47, p=0.0002), and longer ICU LOS (9.51 vs. 6.02, p=0.0273). Patients on 3 agents were 6.52 more likely to have DIC compared to those on 1 agent (OR=6.519, 95% CI 2.72-15.62, p<0.0001). CONCLUSIONS: Patients who required more than one vasoactive agent in the treatment for septic shock had poorer outcomes. With each additional vasoactive agent, there was an increase in 28-day mortality, ICU LOS, days on MV, need for hemodialysis, incidence of DIC, and incidence of arrhythmias. CLINICAL IMPLICATIONS: The higher mortality seen in patients who require multiple vasoactive agents can be a useful prognostic tool for clinicians, especially as it relates to further escalating care and addressing goals of care. DISCLOSURE: The following authors have nothing to disclose: Sung Lee, Boram Kim, Rupa Iyengar, Manideep Duttuluri, Di Pan, Nader Ishak Gabra, Hassan Khouli, Joseph Mathew No Product/Research Disclosure Information