ABSTRACT
Background: Norepinephrine remains the first-line option to manage patients with circulatory shock. Limited evidence exists evaluating noncatecholamine compounds as first-line monotherapy for managing noncardiogenic shock. Objective: To compare vasopressin monotherapy with norepinephrine monotherapy for reversal of distributive and hemorrhagic shock. Methods: This was a retrospective cohort study including adult patients who were diagnosed with hypovolemic or septic shock, received fluids, and received norepinephrine or vasopressin monotherapy for at least 1 hour. Patients excluded lacked a clear diagnosis, were initiated on 2 or more vasopressors at once, or underwent cardiac surgery. The primary outcome was time to shock reversal. Secondary outcomes included mortality, lengths of stay, and safety end points. A multivariable Cox proportional hazards model was performed incorporating baseline and treatment variables. Results: A total of 85 and 160 patients were treated with vasopressin and norepinephrine, respectively. A decrease in time to shock reversal was observed in the vasopressin group (58.32 hours [95% CI, 50.88-66.00] vs 74.64 hours [95% CI, 60.96-88.32], P = 0.004). Mortality was lower in the vasopressin group (25% vs 41%, P = 0.01), and intensive care unit length of stay was longer (13 days [interquartile range, IQR = 7-19] vs 7 days [IQR = 5-9], P = 0.006). Remaining secondary outcomes were similar. The multivariable analysis revealed no difference in time to shock reversal. Conclusion and Relevance: First-line vasopressin exhibited faster time to distributive shock reversal in the unadjusted analysis but failed to maintain this difference in the multivariable analysis. These findings support safe use of vasopressin as first-line therapy or as an alternative to norepinephrine in distributive shock.
Subject(s)
Norepinephrine/therapeutic use , Shock, Hemorrhagic/drug therapy , Shock, Septic/drug therapy , Vasoconstrictor Agents/therapeutic use , Vasopressins/therapeutic use , Adult , Blood Pressure/drug effects , Cohort Studies , Creatinine/blood , Female , Heart Rate/drug effects , Humans , Intensive Care Units , Lactic Acid/blood , Length of Stay , Male , Middle Aged , Norepinephrine/administration & dosage , Norepinephrine/adverse effects , Proportional Hazards Models , Retrospective Studies , Shock, Hemorrhagic/mortality , Shock, Septic/mortality , Treatment Outcome , Vasoconstrictor Agents/administration & dosage , Vasoconstrictor Agents/adverse effects , Vasopressins/administration & dosage , Vasopressins/adverse effectsABSTRACT
PURPOSE: The development and implementation of a pharmacist-led patient-controlled analgesia (PCA) dosing service in a large academic institution are described. SUMMARY: To improve pain management at our institution and expand pharmacy clinical services, a pharmacist-led PCA dosing service was developed and implemented. The service is modeled after established antimicrobial and anticoagulation dosing services at our institution. A core group of pharmacists (service leaders) and a pain physician champion developed a policy and guideline and designed electronic medical record (EMR) tools to support the service. Pharmacists were trained by the service leaders to manage acute pain with fentanyl, hydromorphone, or morphine PCA therapy. Cultural and operational barriers to service implementation were identified and resolved. CONCLUSION: After implementation of the pharmacist-led PCA dosing service, pharmacists at our institution provide PCA pain management services as part of our pharmacy department's standard practice.
