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Evaluation of Vasopressin for Septic Shock in Patients on Chronic Renin-Angiotensin-Aldosterone System Inhibitors

Erwin, Beth L. PharmD, BCCCP1; Denaburg, Michael A. PharmD, BCCCP1; Barker, Andrew B. MD2; McArdle, Philip J. MB, BCh, BAO, FCARCSI2; Windham, Samuel T. MD3; Morgan, Charity J. PhD4

doi: 10.1097/CCM.0000000000002729
Online Clinical Investigations
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Objectives: To compare the hemodynamic response in septic shock patients receiving vasopressin who were on chronic renin-angiotensin-aldosterone system inhibitor therapy with those who were not.

Design: Single-center, retrospective cohort study.

Setting: Medical and surgical ICUs at a 1,100-bed academic medical center.

Patients: Medical and surgical ICU patients with septic shock who received vasopressin infusion added to at least one concomitant vasopressor agent between January 2014 and December 2015, then divided into two cohorts: 1) patients who were on chronic renin-angiotensin-aldosterone system inhibitor therapy as outpatients and 2) patients who were not on chronic renin-angiotensin-aldosterone system inhibitor therapy as outpatients.

Interventions: None.

Measurements and Main Results: Mean arterial pressure at 6 hours was 72.2 mm Hg in the renin-angiotensin-aldosterone system inhibitor group versus 69.7 mm Hg in the non–renin-angiotensin-aldosterone system inhibitor group (p = 0.298). There was no difference in mean arterial pressure at 1, 24, or 48 hours between groups. Total concomitant vasopressor requirements, based on norepinephrine equivalents excluding vasopressin, were significantly lower at 24 hours in the renin-angiotensin-aldosterone system inhibitor group versus the non–renin-angiotensin-aldosterone system inhibitor group (10.7 vs 18.1 µg/min, respectively; p = 0.007), but no significant differences were seen at the other time points assessed. There were no significant differences in ICU or hospital length of stay or mortality.

Conclusions: There was no significant difference in the primary outcome of 6-hour mean arterial pressure in septic shock patients receiving vasopressin who were on chronic renin-angiotensin-aldosterone system inhibitor therapy versus those receiving vasopressin who were not on chronic renin-angiotensin-aldosterone system inhibitor therapy. Renin-angiotensin-aldosterone system inhibitor patients had lower total concomitant vasopressor requirements at 24 hours compared with non–renin-angiotensin-aldosterone system inhibitor patients.

1Department of Pharmacy, University of Alabama at Birmingham Hospital, Birmingham, AL.

2Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, AL.

3Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham Hospital, Birmingham, AL.

4Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL.

This research was performed at University of Alabama at Birmingham Hospital, Birmingham, AL.

The authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Beth L. Erwin, PharmD, BCCCP, University of Alabama at Birmingham Hospital, JT 1728, 619 19th Street South, Birmingham, AL 35249. E-mail: berwin@uabmc.edu

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