Evaluating Rebound Hypotension Following Vasopressor Discontinuation Strategies in Patients With Septic Shock

The 2021 Surviving Sepsis guidelines recommend which vasopressor to initiate first; however, there is a paucity of data to guide the order of vasopressor discontinuation. Retrospective studies have demonstrated an increased risk of hypotension within 24 hours if vasopressin is discontinued first; however, using a shorter timeframe may be of higher clinical relevance and more reflective of vasopressor pharmacokinetic properties.

The purpose of this study was to evaluate differences in the incidence of rebound hypotension within the first 6 hours following norepinephrine or vasopressin discontinuation in patients with septic shock.

This was a single-center, retrospective analysis of adult patients with septic shock admitted to an intensive care unit (ICU) who had either vasopressin (AVP1) or norepinephrine (NE1) discontinued first between January 1, 2021 and December 31, 2021. The major outcome was the incidence of hypotension within 6 hours of first discontinued agent. A Kaplan-Meier curve evaluated time to hypotension. Notable minor outcomes included incidence of hypotension within 12 and 24 hours, ICU length of stay (LOS), ICU mortality, and time to shock resolution.

During the study period, 580 patients were evaluated for inclusion, of which 209 were included: 150 in the NE1 group and 59 in the AVP1 group. There was no difference in incidence of hypotension within 6 (54% vs 61%), 6-12 (14.7% vs 10.2%), or 12-24 (6.7% vs 10.2%) hours, ICU LOS, ICU mortality, and shock resolution between groups. The Kaplan-Meier curve showed no differences between groups in time to hypotension within 6 hours of vasopressor discontinuation (p = 0.1)Conclusion and Relevance:This is the first study to evaluate the impact of vasopressor discontinuation order in septic shock within 6 hours, finding no differences in hypotension regardless of discontinuation order. Application of this data gives reassurance the order of vasopressor discontinuation may not impact clinical outcomes.