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Effects of very early start of norepinephrine in patients with septic shock: a propensity score-based analysis
BACKGROUND: Optimal timing for the start of vasopressors (VP) in septic shock has not been widely studied since it is assumed that fluids must be administered in advance. We sought to evaluate whether a very early start of VP, even without completing the initial fluid loading, might impact clinical...
Autores principales: | , , , , , , , , , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
BioMed Central
2020
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7023737/ https://www.ncbi.nlm.nih.gov/pubmed/32059682 http://dx.doi.org/10.1186/s13054-020-2756-3 |
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author | Ospina-Tascón, Gustavo A. Hernandez, Glenn Alvarez, Ingrid Calderón-Tapia, Luis E. Manzano-Nunez, Ramiro Sánchez-Ortiz, Alvaro I. Quiñones, Egardo Ruiz-Yucuma, Juan E. Aldana, José L. Teboul, Jean-Louis Cavalcanti, Alexandre Biasi De Backer, Daniel Bakker, Jan |
author_facet | Ospina-Tascón, Gustavo A. Hernandez, Glenn Alvarez, Ingrid Calderón-Tapia, Luis E. Manzano-Nunez, Ramiro Sánchez-Ortiz, Alvaro I. Quiñones, Egardo Ruiz-Yucuma, Juan E. Aldana, José L. Teboul, Jean-Louis Cavalcanti, Alexandre Biasi De Backer, Daniel Bakker, Jan |
author_sort | Ospina-Tascón, Gustavo A. |
collection | PubMed |
description | BACKGROUND: Optimal timing for the start of vasopressors (VP) in septic shock has not been widely studied since it is assumed that fluids must be administered in advance. We sought to evaluate whether a very early start of VP, even without completing the initial fluid loading, might impact clinical outcomes in septic shock. METHODS: A total of 337 patients with sepsis requiring VP support for at least 6 h were initially selected from a prospectively collected database in a 90-bed mixed-ICU during a 24-month period. They were classified into very-early (VE-VPs) or delayed vasopressor start (D-VPs) categories according to whether norepinephrine was initiated or not within/before the next hour of the first resuscitative fluid load. Then, VE-VPs (n = 93) patients were 1:1 propensity matched to D-VPs (n = 93) based on age; source of admission (emergency room, general wards, intensive care unit); chronic and acute comorbidities; and lactate, heart rate, systolic, and diastolic pressure at vasopressor start. A risk-adjusted Cox proportional hazard model was fitted to assess the association between VE-VPs and day 28 mortality. Finally, a sensitivity analysis was performed also including those patients requiring VP support for less than 6 h. RESULTS: Patients subjected to VE-VPs received significantly less resuscitation fluids at vasopressor starting (0[0–510] vs. 1500[650–2300] mL, p < 0.001) and during the first 8 h of resuscitation (1100[500–1900] vs. 2600[1600–3800] mL, p < 0.001), with no significant increase in acute renal failure and/or renal replacement therapy requirements. VE-VPs was related with significant lower net fluid balances 8 and 24 h after VPs. VE-VPs was also associated with a significant reduction in the risk of death compared to D-VPs (HR 0.31, CI95% 0.17–0.57, p < 0.001) at day 28. Such association was maintained after including patients receiving vasopressors for < 6 h. CONCLUSION: A very early start of vasopressor support seems to be safe, might limit the amount of fluids to resuscitate septic shock, and could lead to better clinical outcomes. |
format | Online Article Text |
id | pubmed-7023737 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2020 |
publisher | BioMed Central |
record_format | MEDLINE/PubMed |
spelling | pubmed-70237372020-02-20 Effects of very early start of norepinephrine in patients with septic shock: a propensity score-based analysis Ospina-Tascón, Gustavo A. Hernandez, Glenn Alvarez, Ingrid Calderón-Tapia, Luis E. Manzano-Nunez, Ramiro Sánchez-Ortiz, Alvaro I. Quiñones, Egardo Ruiz-Yucuma, Juan E. Aldana, José L. Teboul, Jean-Louis Cavalcanti, Alexandre Biasi De Backer, Daniel Bakker, Jan Crit Care Research BACKGROUND: Optimal timing for the start of vasopressors (VP) in septic shock has not been widely studied since it is assumed that fluids must be administered in advance. We sought to evaluate whether a very early start of VP, even without completing the initial fluid loading, might impact clinical outcomes in septic shock. METHODS: A total of 337 patients with sepsis requiring VP support for at least 6 h were initially selected from a prospectively collected database in a 90-bed mixed-ICU during a 24-month period. They were classified into very-early (VE-VPs) or delayed vasopressor start (D-VPs) categories according to whether norepinephrine was initiated or not within/before the next hour of the first resuscitative fluid load. Then, VE-VPs (n = 93) patients were 1:1 propensity matched to D-VPs (n = 93) based on age; source of admission (emergency room, general wards, intensive care unit); chronic and acute comorbidities; and lactate, heart rate, systolic, and diastolic pressure at vasopressor start. A risk-adjusted Cox proportional hazard model was fitted to assess the association between VE-VPs and day 28 mortality. Finally, a sensitivity analysis was performed also including those patients requiring VP support for less than 6 h. RESULTS: Patients subjected to VE-VPs received significantly less resuscitation fluids at vasopressor starting (0[0–510] vs. 1500[650–2300] mL, p < 0.001) and during the first 8 h of resuscitation (1100[500–1900] vs. 2600[1600–3800] mL, p < 0.001), with no significant increase in acute renal failure and/or renal replacement therapy requirements. VE-VPs was related with significant lower net fluid balances 8 and 24 h after VPs. VE-VPs was also associated with a significant reduction in the risk of death compared to D-VPs (HR 0.31, CI95% 0.17–0.57, p < 0.001) at day 28. Such association was maintained after including patients receiving vasopressors for < 6 h. CONCLUSION: A very early start of vasopressor support seems to be safe, might limit the amount of fluids to resuscitate septic shock, and could lead to better clinical outcomes. BioMed Central 2020-02-14 /pmc/articles/PMC7023737/ /pubmed/32059682 http://dx.doi.org/10.1186/s13054-020-2756-3 Text en © The Author(s). 2020 Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. |
spellingShingle | Research Ospina-Tascón, Gustavo A. Hernandez, Glenn Alvarez, Ingrid Calderón-Tapia, Luis E. Manzano-Nunez, Ramiro Sánchez-Ortiz, Alvaro I. Quiñones, Egardo Ruiz-Yucuma, Juan E. Aldana, José L. Teboul, Jean-Louis Cavalcanti, Alexandre Biasi De Backer, Daniel Bakker, Jan Effects of very early start of norepinephrine in patients with septic shock: a propensity score-based analysis |
title | Effects of very early start of norepinephrine in patients with septic shock: a propensity score-based analysis |
title_full | Effects of very early start of norepinephrine in patients with septic shock: a propensity score-based analysis |
title_fullStr | Effects of very early start of norepinephrine in patients with septic shock: a propensity score-based analysis |
title_full_unstemmed | Effects of very early start of norepinephrine in patients with septic shock: a propensity score-based analysis |
title_short | Effects of very early start of norepinephrine in patients with septic shock: a propensity score-based analysis |
title_sort | effects of very early start of norepinephrine in patients with septic shock: a propensity score-based analysis |
topic | Research |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7023737/ https://www.ncbi.nlm.nih.gov/pubmed/32059682 http://dx.doi.org/10.1186/s13054-020-2756-3 |
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