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Clinical Outcomes of Weight-Based Norepinephrine Dosing in Underweight and Morbidly Obese Patients: A Propensity-Matched Analysis.
J Intensive Care Med. 2020 Jun; 35(6):554-561.JI

Abstract

BACKGROUND

Weight-based dosing strategy for norepinephrine in septic shock patients with extremes of body mass index has been lesser studied.

METHODS

This historical study of adult septic shock patients was conducted from January 1, 2010, to December 31, 2015, at all intensive care units (ICUs) in Mayo Clinic, Rochester. Patients with documented body mass index were classified into underweight (body mass index <18.5 kg/m2), normal weight (18.5-24.9 kg/m2), and morbidly obese (≥40 kg/m2) patients. Patients with repeat ICU admissions, ICU stay <1 day, and body mass index 25 to 39.9 kg/m2 were excluded. The primary outcome was in-hospital mortality, and secondary outcomes included cumulative norepinephrine exposure acute kidney injury, cardiac arrhythmias, and 1-year mortality. Two-tailed P < .05 was considered statistically significant.

RESULTS

From 2010 to 2015, 2016 patients met inclusion-145, 1406, and 466 patients, respectively, in underweight, normal weight, and morbidly obese cohorts. Underweight patients used the highest peak dose and absolute exposure was greatest for morbidly obese patients. In-hospital mortality decreased with increasing log10 body mass index: 41.4% (underweight), 28.4% (normal weight), and 24.7% (morbidly obese), respectively (P < .001); however, this relationship was not noted at 1 year. Unadjusted log10 norepinephrine cumulative exposure (mg) was associated with higher in-hospital mortality, acute kidney injury, cardiac arrhythmias, and 1-year mortality. After adjustment for demographics, body mass index, comorbidity, and illness severity, log10 norepinephrine exposure was an independent predictor of in-hospital mortality (odds ratio 2.4 [95% confidence interval, 2.0-2.8]; P < .001) and 1-year mortality (odds ratio 1.7 [95% confidence interval, 1.5-2.0]; P < .001). In a propensity-matched analysis of 1140 patients, log10 norepinephrine was an independent predictor of in-hospital mortality (odds ratio 2.2 [95% confidence interval, 1.8-2.6]; P < .001).

CONCLUSIONS

Morbidly obese patients had lower in-hospital mortality but had higher 1-year mortality compared to normal weight and underweight patients. Cumulative norepinephrine exposure was highest in morbidly obese patients. Total norepinephrine exposure was an independent mortality predictor in septic shock.

Authors+Show Affiliations

Department of Medicine, Detroit Medical Center/Wayne State University, Detroit, MI, USA. Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Laboratory, Mayo Clinic, Rochester, MN, USA.Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Laboratory, Mayo Clinic, Rochester, MN, USA. Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA. Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Laboratory, Mayo Clinic, Rochester, MN, USA. Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA.Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Laboratory, Mayo Clinic, Rochester, MN, USA. Department of Pharmacy, Mayo Clinic, Rochester, MN, USA.Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Laboratory, Mayo Clinic, Rochester, MN, USA. Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

29628015

Citation

Kotecha, Aditya A., et al. "Clinical Outcomes of Weight-Based Norepinephrine Dosing in Underweight and Morbidly Obese Patients: a Propensity-Matched Analysis." Journal of Intensive Care Medicine, vol. 35, no. 6, 2020, pp. 554-561.
Kotecha AA, Vallabhajosyula S, Apala DR, et al. Clinical Outcomes of Weight-Based Norepinephrine Dosing in Underweight and Morbidly Obese Patients: A Propensity-Matched Analysis. J Intensive Care Med. 2020;35(6):554-561.
Kotecha, A. A., Vallabhajosyula, S., Apala, D. R., Frazee, E., & Iyer, V. N. (2020). Clinical Outcomes of Weight-Based Norepinephrine Dosing in Underweight and Morbidly Obese Patients: A Propensity-Matched Analysis. Journal of Intensive Care Medicine, 35(6), 554-561. https://doi.org/10.1177/0885066618768180
Kotecha AA, et al. Clinical Outcomes of Weight-Based Norepinephrine Dosing in Underweight and Morbidly Obese Patients: a Propensity-Matched Analysis. J Intensive Care Med. 2020;35(6):554-561. PubMed PMID: 29628015.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Clinical Outcomes of Weight-Based Norepinephrine Dosing in Underweight and Morbidly Obese Patients: A Propensity-Matched Analysis. AU - Kotecha,Aditya A, AU - Vallabhajosyula,Saraschandra, AU - Apala,Dinesh R, AU - Frazee,Erin, AU - Iyer,Vivek N, Y1 - 2018/04/08/ PY - 2018/4/10/pubmed PY - 2021/2/20/medline PY - 2018/4/10/entrez KW - mortality KW - norepinephrine KW - obesity KW - septic shock KW - underweight SP - 554 EP - 561 JF - Journal of intensive care medicine JO - J Intensive Care Med VL - 35 IS - 6 N2 - BACKGROUND: Weight-based dosing strategy for norepinephrine in septic shock patients with extremes of body mass index has been lesser studied. METHODS: This historical study of adult septic shock patients was conducted from January 1, 2010, to December 31, 2015, at all intensive care units (ICUs) in Mayo Clinic, Rochester. Patients with documented body mass index were classified into underweight (body mass index <18.5 kg/m2), normal weight (18.5-24.9 kg/m2), and morbidly obese (≥40 kg/m2) patients. Patients with repeat ICU admissions, ICU stay <1 day, and body mass index 25 to 39.9 kg/m2 were excluded. The primary outcome was in-hospital mortality, and secondary outcomes included cumulative norepinephrine exposure acute kidney injury, cardiac arrhythmias, and 1-year mortality. Two-tailed P < .05 was considered statistically significant. RESULTS: From 2010 to 2015, 2016 patients met inclusion-145, 1406, and 466 patients, respectively, in underweight, normal weight, and morbidly obese cohorts. Underweight patients used the highest peak dose and absolute exposure was greatest for morbidly obese patients. In-hospital mortality decreased with increasing log10 body mass index: 41.4% (underweight), 28.4% (normal weight), and 24.7% (morbidly obese), respectively (P < .001); however, this relationship was not noted at 1 year. Unadjusted log10 norepinephrine cumulative exposure (mg) was associated with higher in-hospital mortality, acute kidney injury, cardiac arrhythmias, and 1-year mortality. After adjustment for demographics, body mass index, comorbidity, and illness severity, log10 norepinephrine exposure was an independent predictor of in-hospital mortality (odds ratio 2.4 [95% confidence interval, 2.0-2.8]; P < .001) and 1-year mortality (odds ratio 1.7 [95% confidence interval, 1.5-2.0]; P < .001). In a propensity-matched analysis of 1140 patients, log10 norepinephrine was an independent predictor of in-hospital mortality (odds ratio 2.2 [95% confidence interval, 1.8-2.6]; P < .001). CONCLUSIONS: Morbidly obese patients had lower in-hospital mortality but had higher 1-year mortality compared to normal weight and underweight patients. Cumulative norepinephrine exposure was highest in morbidly obese patients. Total norepinephrine exposure was an independent mortality predictor in septic shock. SN - 1525-1489 UR - https://www.unboundmedicine.com/medline/citation/29628015/Clinical_Outcomes_of_Weight_Based_Norepinephrine_Dosing_in_Underweight_and_Morbidly_Obese_Patients:_A_Propensity_Matched_Analysis_ L2 - https://journals.sagepub.com/doi/10.1177/0885066618768180?url_ver=Z39.88-2003&amp;rfr_id=ori:rid:crossref.org&amp;rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -