In this episode I’ll:
1. Discuss an article about which vasopressor should be stopped first.
2. Answer the drug information question “Do patients with liver disease and prolonged PT/INR levels still need VTE prophylaxis?”
3. Share a resource that reviews noteworthy Emergency Medicine articles from 2017.
Article
Vasoactive Agent Discontinuation Order in Septic Shock
Lead author: Gretchen L. Sacha
Published ahead of print in Pharmacotherapy January 2018
Background
When a patient is being weaned off of multiple vasopressor therapy, pharmacists are often asked which vasopressor should be weaned off first. The ideal order of vasopressor weaning is unknown. The authors of this study evaluated the incidence of hypotension within 24 hours based on the discontinuation order of norepinephrine (NE) and vasopressin (AVP) in patients in the recovery phase of septic shock.
Methods
The study was a retrospective cohort in 3 ICUs within a single academic medical center. 585 adult patients recovering from septic shock were included in the study. Patients had to have received fixed-dose vasopressin therapy for at least 6 hours as an adjunct to norepinephrine. 155 had vasopressin discontinued first, and 430 had norepinephrine discontinued first.
Results
Hypotension was recorded during the 24-hour period after discontinuation of the first vasoactive agent if the mean arterial pressure dropped below 60 mm Hg AND the nurse had to do one or more of the following interventions:
- Increase the remaining vasoactive agent dose by 25%
- Reinstitute the discontinued agent
- Administer at least 1 L of fluid bolus
No significant difference between groups was found with regards to the incidence of hypotension or ICU mortality. After adjustment for baseline factors with multivariable Cox proportional hazards regression, having vasopressin discontinued first was independently associated with an increased risk of hypotension.
Conclusion
The authors concluded:
In patients recovering from septic shock treated with concomitant AVP and NE, no significant difference was noted in the incidence of hypotension based on discontinuation order of these agents.
Discussion
Despite the small statistical difference found with multivariate analysis, there was no clinically significant difference between patients who had norepinephrine discontinued first and patients who had vasopressin discontinued first. This study does not support any recommendation for the order of discontinuation of vasopressor therapy. Because the nurse is the primary person involved in vasopressor discontinuation, I would leave the order up to their preference.
Drug information question
Q: Do patients with liver disease and prolonged PT/INR levels still need VTE prophylaxis?
A: The decision to give a patient with chronic liver disease VTE prophylaxis should be individualized based on the risk of VTE, platelet count, and degree of baseline coagulopathy.
There are few studies that directly address this question, and the ones that do are small and retrospective in nature. Hospitalized patients with liver disease are at risk of VTE. Simply having a prolonged PT or INR does not necessarily mean the patient is “auto-anticoagulated.” A study of 235 patients appears to show that the risk of bleeding is not significantly different in patients with liver disease who receive VTE prophylaxis compared to those who do not. Another study showed a higher risk of bleeding in patients with chronic liver disease, although it was predominantly minor bleeding.
Resource
The resource for this episode is a post by Brian Hayes titled 12 Must-Know Emergency Medicine Pharmacotherapy Articles of 2017. Brian focuses on potentially high-impact articles for improving clinical practice in the emergency department.
Vasopressor choice in sepsis
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
Hi PharmacyJoe,
Are we talking about chemical or pharmacological VTE prophylaxis?