In this episode, I’ll discuss an article about which vasopressor is best in early traumatic brain injury patients.
Patients who have severe traumatic brain injury and develop hypotension that requires vasopressor therapy are already at risk for mortality and poor long term outcomes. But could the choice of vasopressor affect these outcomes? Is the preferred vasopressor for septic and cardiogenic shock (norepinephrine) also good in early severe traumatic brain injury patients?
A group of researchers at Duke University School of Medicine, Durham, North Carolina published a retrospective cohort study to answer these questions in the journal Anesthesia and Analgesia.
The authors analyzed data from over 24,000 adult patients with severe traumatic brain injury who received a vasopressor within the first 2 days of hospital admission. The primary focus was to compare outcomes of norepinephrine vs phenylephrine. In-hospital mortality was the primary outcome while secondary outcomes examined included hospital length of stay (LOS) and ICU LOS.
The study was able to analyze such a large number of patients because it was taken from a large healthcare database and spanned nearly a 10 year period.
About 60% of patients received only phenylephrine, 11% received only norepinephrine, 4% received another vasopressor and 25% received both phenylephrine and norepineprhine.
In propensity-matched analysis, the use of norepinephrine compared to phenylephrine was associated with an increased risk of in-hospital mortality with an odds ratio of 1.65 that was statistically significant.
The study is not perfect as about one-quarter of vasopressor choice was explained by the individual hospital’s usage patterns, which could be a potential confounder despite the propensity matching that was employed to overcome this.
Until a randomized controlled trial is performed, this data represents the largest and most detailed look at which vasopressor to use to treat hypotension associated with severe traumatic brain injury, and suggests that phenylephrine might be preferred over norepinephrine.
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