Variation in Fluid and Vasopressor Use in Shock With and Without Physiologic Assessment: A Multicenter Observational Study

Abstract

Objectives: To characterize the association between the use of physiologic assessment (central venous pressure, pulmonary artery occlusion pressure, stroke volume variation, pulse pressure variation, passive leg raise test, and critical care ultrasound) with fluid and vasopressor administration 24 hours after shock onset and with in-hospital mortality.

Design: Multicenter prospective cohort study between September 2017 and February 2018.

Settings: Thirty-four hospitals in the United States and Jordan.

Patients: Consecutive adult patients requiring admission to the ICU with systolic blood pressure less than or equal to 90 mm Hg, mean arterial blood pressure less than or equal to 65 mm Hg, or need for vasopressor.

Interventions: None.

Measurement and main results: Of 1,639 patients enrolled, 39% had physiologic assessments. Use of physiologic assessment was not associated with cumulative fluid administered within 24 hours of shock onset, after accounting for baseline characteristics, etiology and location of shock, ICU types, Acute Physiology and Chronic Health Evaluation III, and hospital (beta coefficient, 0.04; 95% CI, -0.07 to 0.15). In multivariate analysis, the use of physiologic assessment was associated with a higher likelihood of vasopressor use (adjusted odds ratio, 1.98; 95% CI, 1.45-2.71) and higher 24-hour cumulative vasopressor dosing as norepinephrine equivalent (beta coefficient, 0.37; 95% CI, 0.19-0.55). The use of vasopressor was associated with increased odds of in-hospital mortality (adjusted odds ratio, 1.88; 95% CI, 1.27-2.78). In-hospital mortality was not associated with the use of physiologic assessment (adjusted odds ratio, 0.86; 95% CI, 0.63-1.18).

Conclusions: The use of physiologic assessment in the 24 hours after shock onset is associated with increased use of vasopressor but not with fluid administration.

Figure 1.

The use of physiologic assessment, fluid, and vasopressor in the 24hr following shock onset. A, the use of physiologic assessment and empiric management in the 24hr following shock onset. B, Fluid received at each time period between hour 0–3, hour 3–6, hour 6–12, and hour 12–24. C, Cumulative fluid received from hour 0 to 24. D, The percent of patients with the use of vasopressor at each time period from hour 0–3, hour 3–6, hour 6–12, and hour 12–24. The black box represents empiric management group and the gray box are physiologic assessment group. CCUS = critical care ultrasound, CVP = central venous pressure, PaOP = pulmonary artery occlusion pressure, PLR = passive leg raise, PPV = pulse pressure variation, SVV = stroke volume variation.

Figure 2.

Percent of patients at each site with physiologic assessment and in-hospital mortality, in the order of in-hospital mortality by site. Physiologic assessment intraclass correlation coefficient (ICC) derived from using hospital site as random intercept in random effect model adjusting for age, race, sex, Acute Physiology and Chronic Health Evaluation (APACHE) score, Sequential Organ Failure Assessment (SOFA), maximum lactate level, shock onset location, ICU type, primary shock etiology, cardiac dysfunction, trauma, neurogenic shock as secondary contributor, and mechanical ventilation in the 24hr from shock onset. In-hospital mortality ICC derived from using hospital site as random intercept in random effect model adjusting, use of physiologic assessment, age, race, sex, APACHE score, SOFA, maximum lactate level, hours in hospital prior to shock onset, shock location, ICU types, past medical history of cancer, trauma as a secondary contributor of shock, fluid received, use of vasopressor, and mechanical ventilation in the 24hr following shock and renal replacement therapy.