The Discontinuation Dilemma: Which Vasopressor Should Be Weaned First in Patients Recovering From Shock?

Hyeong Kim; Pooja Desa; Edwin Avallone; Thomas Weart; David Adkins

PURPOSE: There is a paucity of data on which order to wean vasopressors in patients recovering from shock. A single study with a small sample size has shown a higher incidence of hypotension when vasopressin (VP) was discontinued before norepinephrine (NE). This study aimed to evaluate possible adverse outcomes associated with the order of vasopressor discontinuation.

METHODS: A retrospective cohort study was performed in shock patients who were concomitantly treated with NE and VP. Sample sizes were calculated to have at least 60 patients in NE group and 30 in VP group, taking conservative figures from a prior study. Patients were divided into two groups depending on whether NE or vasopressin was discontinued first in weaning vasopressors. The primary outcome was the incidence of hypotension within 24 hours of discontinuation of the first vasopressor and before the discontinuation of the remaining agent. The secondary outcome was length of hospital stay

RESULTS: Of 195 patients identified eligible, NE was discontinued first in 148 patients (NE group) and VP discontinued first in 47 patients (VP group). There was no difference in incidence of hypotension between the groups (44 patients [30%] in NE group vs. 14 patients [30%] in VP group, p=0.994). No difference in hypotension was also observed in a subgroup analysis in 150 patients with septic shock (33 out of 117 patients in NE group [28%] vs. 10 out of 33 patients in VP group [30%], p=0.814). There was no difference in the secondary outcome, length of hospital stay, between the two groups (25 days in NE group vs. 26 days in VP group, p=0.619).

CONCLUSIONS: In patients recovering from shock concurrently treated with NE and VP, there was no difference in incidence of hypotension either when NE or VP was discontinued before the other during vasopressor weaning. There was no difference in length of hospital stay between the groups. The same findings were observed in a subgroup of septic patients.

Chest. 2014;146(4_MeetingAbstracts):238A. doi:10.1378/chest.1990619