Hemodynamic Treatment Aimed to Reduce Catecholamine Toxicity in Patients Suffering from Septic Shock: An Observational Single Center Study

Abstract

Aims: Catecholamines represent a cornerstone in the hemodynamic management of septic shock (SS). However, development of toxicity may adversely affect patient outcome. We describe the outcome of 460 consecutive SS patients who were treated with an institutional hemodynamic protocol aimed at decreasing catecholamine toxicity. Study Design: Retrospective observational analysis. Place and Duration of Study: Multidisciplinary intensive care unit in a 460 bed hospital between January 1, 2004 to July 31, 2010. Methodology: Demographic data, premorbidities, admission Simplified Acute Physiology Score (SAPS) II, most aberrant laboratory data, highest dosages of norepinephrine (NE), dobutamine, milrinone, use of ß-adrenoreceptor blocking agents, hydrocortisone and arginine vasopressin (AVP), development of new-onset tachyarrhythmia and myocardial ischemia were analyzed from an electronic database. The institutional hemodynamic treatment protocol includes early administration of hydrocortisol and arginine vasopressin in addition to norepinephrine and aggressive treatment of hyperthermia (T>38.5º). New onset tachyarrhythmia’s/tachycardia were treated using amiodarone and ß-adrenoreceptor blockers to decrease heart rate below 95bpm, respectively. Observed and SAPS-predicted mortality were analyzed for all patients and SAPS-quartiles (QI-QIV) of increasing disease severity. Results: Age, incidence of preexisting heart, renal disease, arterial hypertension, and MODS increased while body mass index significantly declined from QI to QIV. With increasing disease severity, patients received higher dosages of NE, steroids, AVP and milrinone. The incidence of tachycardic atrial fibrillation and myocardial ischemia increased from QI to QIV. Overall, there was no significant difference between the observed and SAPS II predicted mortality (p=0.2, Chi2-test). However, we observed a trend (-12, 2%) towards decreased mortality in QIII (p=0.07) and a significant decrease in hospital mortality (-19%) in QIV (p<0.0001; Chi2-test). Conclusions: Our data suggest that a treatment protocol aimed at decreasing catecholamine toxicity including early administration of hydrocortisone, AVP, aggressive body temperature and heart rate control may decrease SS mortality, particularly in elderly, premorbid patients suffering from advanced SS.