Impact of the Sequence of Norepinephrine and Vasopressin Discontinuation in Patients Recovering From Septic Shock.

Background: Septic shock is a serious medical condition affecting millions of people each year and guidelines direct vasopressor use in these patients. However, there is little information as to which vasopressor should be discontinued first. Objective: The objective of this study was to assess the impact of the sequence of norepinephrine and vasopressin discontinuation on intensive care unit (ICU) length of stay. Methods: This was a single-center retrospective cohort study conducted at The University of Tennessee Medical Center in Knoxville, Tennessee. Patients included in this study were adults 18 years of age and older with a diagnosis of septic shock who received norepinephrine in combination with vasopressin. Patients were excluded if norepinephrine or vasopressin were not the last 2 vasoactive agents used or if the patient expired or care was withdrawn. Measurements and Main Results: A total of 86 patients were included in this study, with 34 patients in the norepinephrine discontinued first group (NDF) and 52 in the vasopressin discontinued first group (VDF). For the primary outcome of ICU length of stay, no statistically significant difference was found between the NDF and the VDF groups (9.38 days vs 11.07 days, P = .313). The secondary outcome of the dose of norepinephrine at which vasopressin was initiated was also found to not be significant between the NDF and VDF groups (22 µg/min vs 31.1 µg/min, P = .11). The rates of hypotension within 24 hours of discontinuation of the first agent were also not significant between the NDF and VDF groups (17% vs 31%, P = .38). Conclusions: Based on the results of this study, there was significant no difference in ICU length of stay based on the sequence of discontinuation between norepinephrine and vasopressin in patients recovering from septic shock.

Deprescribing opportunities for elderly inpatients in an academic, safety-net health system.

BACKGROUND: Deprescribing is one way to reduce inappropriate polypharmacy in older adult patients. Although algorithms have been published to guide practitioners in deprescribing, it is still unknown how applicable these algorithms are to the general older adult population. OBJECTIVES: The primary objective was to assess the applicability of published deprescribing protocols in hospitalized older adult patients. METHODS: This retrospective study included patients aged 65 years or greater who were discharged from an internal medicine team between January 1, 2017 and June 30, 2017. Along with age and admission to internal medicine wards, other eligibility criteria were extracted from published deprescribing protocols. The primary endpoint was the proportion of patients eligible for deprescribing based on published algorithms. Secondary endpoints included the proportion of patients receiving medications which were included in an algorithm, proportion of patients using medications included in the algorithms who were eligible for deprescribing, and proportion of patients with medications deprescribed during the hospital stay. RESULTS: Two hundred sixty-seven patients were included and 124 (46.4%) used a medication with a published deprescribing algorithm. Thirty-four percent of all patients and 74% (92/124) of patients prescribed medications included in algorithms were eligible for deprescribing. Seven percent (6/92) of patients eligible for deprescribing had medications deprescribed during the hospital stay. CONCLUSION: The application of deprescribing algorithms in hospitalized older adults identified a significant opportunity to initiate deprescribing practices.