Strategies for discontinuing vasopressin and norepinephrine during the recovery phase of shock: a single-center retrospective study.

Abstract

Background: The optimal strategy for discontinuing arginine vasopressin and norepinephrine in patients recovering from shock remains uncertain. Although prior studies have suggested a higher risk of hypotension when arginine vasopressin is discontinued first, these findings may have been influenced by baseline imbalances and tapering practices. We conducted a retrospective study to evaluate whether the order of discontinuation between arginine vasopressin and norepinephrine was associated with the incidence of hypotension during the recovery phase of shock, with vasopressor end doses converted to norepinephrine equivalents for analysis.

Methods: This was a single-center retrospective cohort study of intensive care unit patients with shock who received both arginine vasopressin and norepinephrine from August 2017 to March 2024. Patients were categorized based on whether arginine vasopressin or norepinephrine was discontinued first. The primary outcome was the incidence of hypotension within 24 h of vasopressor cessation, defined as mean arterial pressure < 60 mmHg requiring a ≥ 25% increase in the remaining vasopressor, reinstitution of the stopped agent, or a bolus of ≥ 500 mL crystalloid or 25 g albumin. Overlap weighting using propensity scores was applied to adjust for baseline imbalances both in the overall cohort and in the septic shock subgroup. Propensity scores were estimated using logistic model, including baseline characteristics, hemodynamic parameters, and vasopressor end doses in norepinephrine equivalents.

Results: A total of 524 patients were analyzed, with 293 discontinuing AVP first and 231 discontinuing NE first. In the unadjusted cohorts, hypotension occurred in 19% of the AVP-first group and 26% of the NE-first group. After overlap weighting, all baseline covariates were balanced between the groups, and the incidence of hypotension was not significantly different (19% vs 21%, P = 0.59). In the septic shock subgroup (n = 267), the weighted analysis showed no significant difference in the incidence of hypotension between groups.

Conclusions: In patients recovering from shock who received both arginine vasopressin and norepinephrine, discontinuing arginine vasopressin first was not associated with a higher risk of hypotension.