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Alshehri AM, Kovacevic MP, Dube KM, Lupi KE, DeGrado JR. Comparison of Early Versus Late Adjunctive Vasopressin and Corticosteroids in Patients With Septic Shock. Ann Pharmacother 2024; 58:461-468. [PMID: 37542417 DOI: 10.1177/10600280231191131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND Vasopressin (VP) and hydrocortisone (HC) have been shown to improve outcomes in patients with septic shock. However, there is very little literature addressing the impact of the timing of the combination. OBJECTIVE This study was conducted to evaluate the impact of early versus late initiation of both VP and HC on time to shock reversal in septic shock patients. METHODS This was a retrospective study conducted at a tertiary academic medical center. Data were collected from system-generated reports, which were used to identify patients with septic shock who were admitted to an intensive care unit (ICU) and received both VP and HC. The primary endpoint was time to shock reversal. Patients were divided into the "early" group if both VP and HC were initiated within 12 hours of vasopressor initiation or into the "late" group if either VP or HC (or both agents) were initiated after 12 hours of vasopressor initiation. RESULTS A total of 122 patients were included in the analysis. Early initiation was associated with a shorter time to shock reversal (34 hours vs 65 hours; P = 0.012) compared to late initiation. There were no differences in ICU length of stay, mortality, the number patients requiring renal replacement therapy, or the duration of mechanical ventilation in either group. CONCLUSION AND RELEVANCE Our study addressed a major gap in the literature and suggests that adding the combination of VP and HC within 12 hours of septic shock may be associated with improved patient outcomes.
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Affiliation(s)
| | - Mary P Kovacevic
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Kevin M Dube
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Kenneth E Lupi
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Jeremy R DeGrado
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
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Lock AE, Gutierrez GC, Hand EO, Barthol CA, Attridge RL. Fludrocortisone Plus Hydrocortisone Versus Hydrocortisone Alone as Adjunctive Therapy in Septic Shock: A Retrospective Cohort Study. Ann Pharmacother 2023; 57:1375-1388. [PMID: 37026172 DOI: 10.1177/10600280231164210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Trials evaluating hydrocortisone (HC) for septic shock are conflicting with all finding decreased time to shock reversal but few with mortality difference. Those with improved mortality included fludrocortisone (FC), but it is unknown if FC affected the outcome or is coincidental as there are no comparative data. OBJECTIVE The objective of this study was to determine the effectiveness and safety of FC + HC versus HC alone as adjunctive therapy in septic shock. METHODS A single-center, retrospective cohort study was conducted of medical intensive care unit (ICU) patients with septic shock refractory to fluids and vasopressors. Patients receiving FC + HC were compared with those receiving HC. Primary outcome was time to shock reversal. Secondary outcomes included in-hospital, 28-, and 90-day mortality; ICU and hospital length of stay (LOS); and safety. RESULTS There were 251 patients included (FC + HC, n = 114 vs HC, n = 137). There was no difference in time to shock reversal (65.2 vs 71 hours; P = 0.24). Cox proportional hazards model showed time to first corticosteroid dose, full-dose HC duration, and use of FC + HC were associated with shorter shock duration, while time to vasopressor therapy was not. However, in 2 multivariable models controlling for covariates, use of FC + HC was not an independent predictor of shock reversal at greater than 72 hours and in-hospital mortality. No differences were seen in hospital LOS or mortality. Hyperglycemia occurred more frequently with FC + HC (62.3% vs 45.6%; P = 0.01). CONCLUSION AND RELEVANCE FC + HC was not associated with shock reversal at greater than 72 hours or decreased in-hospital mortality. These data may be useful for determining corticosteroid regimen in patients with septic shock refractory to fluids and vasopressors. Future prospective, randomized studies are needed to further evaluate the role of FC in this patient population.
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Affiliation(s)
- Ashley E Lock
- Department of Pharmacotherapy and Pharmacy Services, University Health, San Antonio, TX, USA
- Division of Pharmacotherapy, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, UT Health San Antonio, San Antonio, TX, USA
- Department of Emergency Medicine, Long School of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - G Christina Gutierrez
- Department of Pharmacotherapy and Pharmacy Services, University Health, San Antonio, TX, USA
- Division of Pharmacotherapy, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, UT Health San Antonio, San Antonio, TX, USA
| | - Elizabeth O Hand
- Department of Pharmacotherapy and Pharmacy Services, University Health, San Antonio, TX, USA
- Division of Pharmacotherapy, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, UT Health San Antonio, San Antonio, TX, USA
| | - Colleen A Barthol
- Department of Pharmacotherapy and Pharmacy Services, University Health, San Antonio, TX, USA
- Division of Pharmacotherapy, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, UT Health San Antonio, San Antonio, TX, USA
| | - Rebecca L Attridge
- Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX, USA
- Department of Medicine, Division of Pulmonary Diseases and Critical Care, UT Health San Antonio, San Antonio, TX, USA
- The Craneware Group, Deerfield Beach, FL, USA
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3
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Alsulami M, Alrojaie L, Omaer A. Early Versus Late Initiation of Hydrocortisone in Patients With Septic Shock: A Prospective Study. Cureus 2023; 15:e50814. [PMID: 38249261 PMCID: PMC10797220 DOI: 10.7759/cureus.50814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction The optimal timing of corticosteroid initiation in septic shock patients is debatable. The Surviving Sepsis Campaign Guidelines recommended adding hydrocortisone to septic shock patients who require a vasopressor with a dose of norepinephrine ≥ 0.25 mcg/kg/min for at least four hours. Nevertheless, the best time to initiate hydrocortisone remains uncertain. Objective Assessing the impact of early (≤3 hours) versus late (>3 hours) initiation of hydrocortisone in septic patients. Methodology We compared the outcomes of septic shock patients who received hydrocortisone within three hours versus those who started treatment after three hours. The inclusion criteria encompassed septic shock patients aged 18 or older who received at least one dose of hydrocortisone. Exclusion criteria included pregnancy, do-not-resuscitate orders, the absence of empirical intravenous antibiotics, recent corticosteroid use, recent cardiac arrest, and a history of adrenal insufficiency. Results Eighty-one patients were included (54% were males). The mean age was 59 years, and 56.8% of patients were in the early group. The time needed to discontinue vasopressors was 25 and 37 hours for the early and late groups, respectively (p = 0.009), and more patients achieved reversal of shock (35 vs. 24 patients) and had shorter ICU stays (17 days vs. 20 days). Conclusion Initiating hydrocortisone early, within three hours, reduced the time needed to discontinue vasopressors among the study population. However, both early and late initiation strategies yielded comparable outcomes in terms of ICU mortality, ICU length of stay, and shock reversal.
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Zhang L, Gu WJ, Huang T, Lyu J, Yin H. The Timing of Initiating Hydrocortisone and Long-term Mortality in Septic Shock. Anesth Analg 2023; 137:850-858. [PMID: 37171987 DOI: 10.1213/ane.0000000000006516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
BACKGROUND Previous studies on the association between the timing of corticosteroid administration and mortality in septic shock focused only on short-term mortality and produced conflicting results. We performed a retrospective review of a large administrative database of intensive care unit (ICU) patients to evaluate the association between the timing of hydrocortisone initiation and short- and long-term mortality in septic shock. We hypothesized that a longer duration between the first vasopressor use for sepsis and steroid initiation was associated with increased mortality. METHODS Data were extracted from the Medical Information Mart in the Intensive Care-IV database. We included adults who met Sepsis-3 definition for septic shock and received hydrocortisone. The exposure of interest was the time in hours from vasopressor use to hydrocortisone initiation (>12 as late and ≤12 as early). The primary outcome was 1-year mortality. Secondary outcomes included 28-day mortality, 90-day mortality, in-hospital mortality, and length of hospital stay. Cox proportional hazard models were used to estimate the association between exposure and mortality. Competing risk regression models were used to evaluate the association between exposure and length of hospital stay. RESULTS A total of 844 patients were included in this cohort: 553 in the early group and 291 in the late group. The median time to hydrocortisone initiation was 7 hours (interquartile range, 2.0-19.0 hours). After multivariable Cox proportional hazard analysis, we found that hydrocortisone initiation >12 hours after vasopressor use was associated with increased 1-year mortality when compared with initiation <12 hours (adjusted hazard ratio, 1.39; 95% confidence interval, 1.13-1.71; P = .002, E-value = 2.13). Hydrocortisone initiation >12 hours was also associated with increased 28-day, 90-day, and in-hospital mortality and prolonged length of hospital stay. CONCLUSIONS In patients with septic shock, initiating hydrocortisone >12 hours after vasopressor use was associated with an increased risk of both short-term and long-term mortality, and a prolonged length of hospital stay.
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Affiliation(s)
- Luming Zhang
- From the Departments of Intensive Care Unit
- Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Wan-Jie Gu
- From the Departments of Intensive Care Unit
- Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Tao Huang
- Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jun Lyu
- Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Haiyan Yin
- Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
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Suh GJ, shin TG, Kwon WY, Kim K, Jo YH, Choi SH, Chung SP, Kim WY. Hemodynamic management of septic shock: beyond the Surviving Sepsis Campaign guidelines. Clin Exp Emerg Med 2023; 10:255-264. [PMID: 37439141 PMCID: PMC10579730 DOI: 10.15441/ceem.23.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/19/2023] [Accepted: 06/19/2023] [Indexed: 07/14/2023] Open
Abstract
Although the Surviving Sepsis Campaign guidelines provide standardized and generalized guidance, they are less individualized. This review focuses on recent updates in the hemodynamic management of septic shock. Monitoring and intervention for septic shock should be personalized according to the phase of shock. In the salvage phase, fluid resuscitation and vasopressors should be given to provide life-saving tissue perfusion. During the optimization phase, tissue perfusion should be optimized. In the stabilization and de-escalation phases, minimal fluid infusion and safe fluid removal should be performed, respectively, while preserving organ perfusion. There is controversy surrounding the use of restrictive versus liberal fluid strategies after initial resuscitation. Fluid administration after initial resuscitation should depend upon the patient's fluid responsiveness and requires individualized management. A number of dynamic tests have been proposed to monitor fluid responsiveness, which can help clinicians decide whether to give fluid or not. The optimal timing for the initiation of vasopressor agents is unknown. Recent data suggest that early vasopressor initiation should be considered. Inotropes can be considered in patients with decreased cardiac contractility associated with impaired tissue perfusion despite adequate volume status and arterial blood pressure. Venoarterial extracorporeal membrane oxygenation should be considered for refractory septic shock with severe cardiac systolic dysfunction.
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Affiliation(s)
- Gil Joon Suh
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Tae Gun shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - You Hwan Jo
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sung-Hyuk Choi
- Department of Emergency Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - for the Korean Shock Society Investigators
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Emergency Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of Emergency Medicine, Korea University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kulesza S, Gignac L, Colvin CA, Boll S, Giuliano C, Haan B, Allen B, Perez MM, Allen M, Edwin SB. Hydrocortisone versus vasopressin for the management of adult patients with septic shock refractory to norepinephrine: A multicenter retrospective study. Pharmacotherapy 2023; 43:787-794. [PMID: 37148191 DOI: 10.1002/phar.2811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/03/2023] [Accepted: 04/10/2023] [Indexed: 05/08/2023]
Abstract
STUDY OBJECTIVE Significant practice variation exists when selecting between hydrocortisone and vasopressin as second line agents in patients with septic shock in need of escalating doses of norepinephrine. The goal of this study was to assess differences in clinical outcomes between these two agents. DESIGN Multicenter, retrospective, observational study. SETTING Ten Ascension Health hospitals. PATIENTS Adult patients with presumed septic shock receiving norepinephrine prior to study drug initiation between December 2015 and August 2021. INTERVENTION Vasopressin (0.03-0.04 units/min) or hydrocortisone (200-300 mg/day). MEASUREMENTS AND MAIN RESULTS A total of 768 patients were included with a median (interquartile range) SOFA score of 10 (8-13), norepinephrine dose of 0.3 mcg/kg/min (0.1-0.5 mcg/kg/min), and lactate of 3.8 mmol/L (2.4-7.0 mmol/L) at initiation of the study drug. A significant difference in 28-day mortality was noted favoring hydrocortisone as an adjunct to norepinephrine after controlling for potential confounding factors (OR 0.46 [95% CI, 0.32-0.66]); similar results were seen following propensity score matching. Compared to vasopressin, hydrocortisone initiation was also associated with a higher rate of hemodynamic responsiveness (91.9% vs. 68.2%, p < 0.01), improved resolution of shock (68.8% vs. 31.5%, p < 0.01), and reduced recurrence of shock within 72 h (8.7% vs. 20.7%, p < 0.01). CONCLUSIONS Addition of hydrocortisone to norepinephrine was associated with a lower 28-day mortality in patients with septic shock, compared to the addition of vasopressin.
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Affiliation(s)
- Steven Kulesza
- Department of Pharmacy, Ascension St. John Hospital, Detroit, Michigan, USA
| | - Lindsey Gignac
- Department of Pharmacy, Ascension St Vincent's Riverside Hospital, Jacksonville, Florida, USA
| | - C Allis Colvin
- Department of Pharmacy, Ascension St Vincent's Birmingham Hospital, Birmingham, Alabama, USA
| | - Skyler Boll
- Department of Pharmacy, Ascension Genesys Hospital, Grand Blanc, Michigan, USA
| | - Christopher Giuliano
- Department of Pharmacy, Ascension St. John Hospital, Detroit, Michigan, USA
- Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Bradley Haan
- Department of Pharmacy, Ascension Genesys Hospital, Grand Blanc, Michigan, USA
| | - Bryan Allen
- Department of Pharmacy, Ascension St Vincent's Riverside Hospital, Jacksonville, Florida, USA
| | - Mary M Perez
- Department of Pharmacy, Ascension St Vincent's Birmingham Hospital, Birmingham, Alabama, USA
| | - Monica Allen
- Department of Pharmacy, Ascension Genesys Hospital, Grand Blanc, Michigan, USA
| | - Stephanie B Edwin
- Department of Pharmacy, Ascension St. John Hospital, Detroit, Michigan, USA
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Samaan O, Bojorquez D, Tallman GB. Comment: Comparison of Early Versus Late Initiation of Hydrocortisone in Patients With Septic Shock in the ICU Setting. Ann Pharmacother 2022; 57:751-752. [PMID: 36114709 DOI: 10.1177/10600280221124510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Ragoonanan D, Tran N, Modi V, Morgan Nickelsen P. Unanswered questions on use of hydrocortisone, ascorbic acid, and thiamine therapy in sepsis and septic shock. Am J Health Syst Pharm 2022; 79:1626-1633. [PMID: 35701085 DOI: 10.1093/ajhp/zxac169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To evaluate current evidence on the utility of hydrocortisone, ascorbic acid and thiamine (HAT) therapy for the management of septic shock. SUMMARY The following keyword search terms were utilized in PubMed to identify relevant articles: ascorbic acid, thiamine, hydrocortisone, shock, and critical care. Articles relevant to HAT therapy in patients with septic shock were selected. Retrospective cohorts and randomized controlled trials were included in this review; case reports/series were excluded. Data from included studies illustrating the use of HAT therapy for the management of sepsis and septic shock, including data on time to HAT therapy initiation, severity of illness at baseline, duration of vasopressor therapy, progression of organ failure, and mortality, were evaluated. CONCLUSION The utilization of HAT therapy for the management of sepsis and septic shock remains controversial. Hemodynamic benefits have been shown to be most pronounced when HAT therapy is initiated earlier. Future studies directed at earlier initiation may be necessary to confirm this theory.
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Affiliation(s)
- David Ragoonanan
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Nicolas Tran
- Department of Pharmacy Services, Tampa General Hospital, Tampa, FL, USA
| | - Veeshal Modi
- Division of Pulmonary/Critical Care, University of South Florida, Tampa, FL, USA
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Ammar MA, Ammar AA, Wieruszewski PM, Bissell BD, T Long M, Albert L, Khanna AK, Sacha GL. Timing of vasoactive agents and corticosteroid initiation in septic shock. Ann Intensive Care 2022; 12:47. [PMID: 35644899 PMCID: PMC9148864 DOI: 10.1186/s13613-022-01021-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/09/2022] [Indexed: 12/20/2022] Open
Abstract
Septic shock remains a health care concern associated with significant morbidity and mortality. The Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock recommend early fluid resuscitation and antimicrobials. Beyond initial management, the guidelines do not provide clear recommendations on appropriate time to initiate vasoactive therapies and corticosteroids in patients who develop shock. This review summarizes the literature regarding time of initiation of these interventions. Clinical data regarding time of initiation of these therapies in relation to shock onset, sequence of treatments with regard to each other, and clinical markers evaluated to guide initiation are summarized. Early-high vasopressor initiation within first 6 h of shock onset is associated with lower mortality. Following norepinephrine initiation, the exact dose and timing of escalation to adjunctive vasopressor agents are not well elucidated in the literature. However, recent data indicate that timing may be an important factor in initiating vasopressors and adjunctive therapies, such as corticosteroids. Norepinephrine-equivalent dose and lactate concentration can aid in determining when to initiate vasopressin and angiotensin II in patients with septic shock. Future guidelines with clear recommendations on the time of initiation of septic shock therapies are warranted.
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Affiliation(s)
- Mahmoud A Ammar
- Department of Pharmacy, Yale New Haven Health System, 20 York Street, New Haven, CT, 06510, USA.
| | - Abdalla A Ammar
- Department of Pharmacy, Yale New Haven Health System, 20 York Street, New Haven, CT, 06510, USA
| | - Patrick M Wieruszewski
- Departments of Anesthesiology and Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Brittany D Bissell
- Department of Pulmonary, Critical Care, and Sleep Medicine, College of Medicine, University of Kentucky, Lexington, KY, USA.,Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Micah T Long
- Department of Anesthesiology, University of Wisconsin Hospitals and Clinics, 600 Highland Ave, Madison, WI, USA
| | - Lauren Albert
- Department of Pharmacy, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Center for Biomedical Informatics, Perioperative Outcomes and Informatics Collaborative, Medical Center Boulevard, Winston-Salem, NC, USA.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Gretchen L Sacha
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Avenue, Hb-105, Cleveland, OH, USA
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