Novel Considerations in the Management of Shock. Vasopressors, Fluid Responsiveness, and Blood Pressure Targets

• Published in: American journal of respiratory and critical care medicine Vol. 199; no. 9; pp. 1148 - 1150
• Main Authors: Khan, Yasin A, Spring, Jenna, Morales-Castro, Diana, McCredie, Victoria A
• Format: Journal Article
• Language: English
• Published: United States American Thoracic Society 01-05-2019
• Subjects: Angiotensin II; Blood Pressure; Body fluids; Drug therapy; Humans; Hypotension; Sepsis; Shock; Shock (Circulatory); Vasoconstrictor Agents
• ISSN: 1073-449X; 1535-4970
• DOI: 10.1164/rccm.201804-0746RR

[...]because Ang-II has recently been approved by the U.S. Food and Drug Administration for managing septic shock (10), we should expect to gain more insight about how it interacts and compares with existing vasopressors with respect to efficacy, safety, and clinical outcomes. Fluid responsiveness was defined as a static measurement of sustained reversal of hypotension (with resultant systolic blood pressure [SBP] >90 mm Hg or MAP >65 mm Hg) after initial fluid resuscitation without the use of vasopressors for 24 hours. Fluid-refractory patients had higher in-hospital mortality rates (37% [95% CI, 35-40] vs. 23% [95% CI, 22-25]), as well as higher rates of ICU admission (76% [95% CI, 73-78] vs. 57% [95% CI, 55-59]) and mechanical ventilation (47% [95% CI, 45-50] vs. 32% [95% CI, 30-34]), with longer ICU (12.8 d [95% CI, 10.9-14.7] vs. 7.7 d [95% CI, 6.6-8.7]) and hospital lengths of stay (22.8 d [95% CI, 20.8-24.8] vs. 16.0 d [95% CI, 14.9-17.0]). In a multivariate logistic regression, the following variables were predictors of fluid refractoriness: congestive heart failure (CHF) (adjusted odds ratio [AOR], 1.33; 95% CI, 1.10-1.60), hypothermia (AOR, 1.33; 95% CI, 1.07-1.65), lactate greater than or equal to 4 mmol/L (AOR, 1.56; 95% CI, 1.30-1.86), immunocompromise (AOR, 1.29; 95% CI, 1.07-1.54), coagulopathy (AOR, 1.21; 95% CI, 1.01-1.46), diagnosis of sepsis as an inpatient (AOR, 1.36; 95% CI, I.05-1.75), and delayed fluid resuscitation with time to fluid resuscitation longer than 120 minutes as the strongest risk factor (AOR, 1.96; 95% CI, 1.49-2.58).