• Samuel M Brown, Michael J Lanspa, Jason P Jones, Kathryn G Kuttler, Yao Li, Rick Carlson, Russell R Miller, Eliotte L Hirshberg, Colin K Grissom, and Alan H Morris.
• Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT.
• Chest. 2013 Mar 1; 143 (3): 664671664-671.

BackgroundSome patients with hypotensive shock do not respond to usual doses of vasopressor therapy. Very little is known about outcomes after high-dose vasopressor therapy (HDV). We sought to characterize survival among patients with shock requiring HDV. We also evaluated the possible utility of stress-dose corticosteroid therapy in these patients.MethodsWe conducted a retrospective study of patients with shock requiring HDV in the ICUs of five hospitals from 2005 through 2010. We defined HDV as receipt at any point of ≥ 1 μg/kg/min of norepinephrine equivalent (calculated by summing norepinephrine-equivalent infusion rates of all vasopressors). We report survival 90 days after hospital admission. We evaluated receipt of stress-dose corticosteroids, cause of shock, receipt of CPR, and withdrawal or withholding of life support therapy.ResultsWe identified 443 patients meeting inclusion criteria. Seventy-six (17%) survived. Survival was similar (20%) among the 241 patients with septic shock. Among the 367 nonsurvivors, 254 (69%) experienced withholding/withdrawal of care, and 115 (31%) underwent CPR. Stress-dose corticosteroid therapy was associated with increased survival (P = .01).ConclusionsOne in six patients with shock survived to 90 days after HDV. The majority of nonsurvivors died after withdrawal or withholding of life support therapy. A minority of patients underwent CPR. Additionally, stress-dose corticosteroid therapy appears reasonable in patients with shock requiring HDV.

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