32: DISCONTINUATION ORDER OF NE VS. AVP DURING SEPTIC SHOCK RECOVERY SYSTEMATIC REVIEW & META-ANALYSIS

Abstract

Learning Objectives: The Surviving Sepsis Campaign provides little guidance on vasopressor discontinuation among patients resolving from septic shock. Recent studies have observed conflicting results in the development of clinically significant hypotension depending on vasopressor discontinuation order. This systematic review and meta-analysis was performed to elucidate the impact discontinuation order of norepinephrine (NE) or vasopressin (AVP) has on clinical outcomes in patients resolving septic shock. Methods: We conducted a systematic search from January 2007 to June 2018 of peer-reviewed clinical studies evaluating discontinuation order of NE and AVP in septic shock. A 2-stage individual patient data meta-analysis was performed to assess pooled estimates for the development of clinically significant hypotension, intensive care unit (ICU) length of stay (LOS), hospital LOS, and combined hospital and ICU mortality when NE or AVP is discontinued first among patients resolving from septic shock. Patient outcome data for each study were first adjusted based on baseline differences between group using multivariable regression, and then combined using generic inverse variance weighting. Missing data were handled using multiple imputations. Analyses were performed using random-effects model and heterogeneity assessed by I2. Results: A total of 106 unique studies were identified in database search. Of those screened, 6 were included (n = 957). Discontinuation of NE first demonstrated a lower odds of clinically significant hypotension (OR=0.22; 95% CI 0.07–0.68; P<0.001, I2=87%) but no differences were observed in ICU LOS (mean difference= 0.15 days; 95% CI -1.58–1.88 days; P=0.86, I2=21%), hospital LOS (mean difference= 1.65 days; 95% CI -0.47–3.76; P=0.13, I2=0%), or combined hospital and ICU mortality (OR=1.12; 95% CI 0.67– 1.68; I2=45%). Conclusions: This meta-analysis revealed that discontinuation of NE first was associated with lower odds of developing clinically significant hypotension. Despite this, NE discontinuation first was not associated with lower ICU LOS, hospital LOS, or combined ICU and hospital mortality. Further prospective studies are warranted to explore the impact of vasoactive medication discontinuation order. CCMCritical Care MedicineCrit Care Med0090-3493Lippincott Williams & WilkinsHagerstown, MDCCM