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Modeling of Usual Care: Vasopressor Initiation for Sepsis With Hypotension
Name
fmed-09-715856.pdf
Description
Published version
Size
1.02 MB
Format
Adobe PDF
Checksum (MD5)
d2e28639169d8177458e4e29822fb492
Author(s)
Prasad, Varesh
Reisner, Andrew T
Lynch, James C
Filbin, Michael R
Heldt, Thomas
Date Issued
2022
Journal
Frontiers in Medicine
Publisher
Frontiers Media SA
Citation
Prasad, Varesh, Reisner, Andrew T, Lynch, James C, Filbin, Michael R and Heldt, Thomas. 2022. "Modeling of Usual Care: Vasopressor Initiation for Sepsis With Hypotension." Frontiers in Medicine, 9.
Version
Final published version
Abstract
Usual care regarding vasopressor initiation is ill-defined. We aimed to develop a quantitative “dynamic practice” model for usual care in the emergency department (ED) regarding the timing of vasopressor initiation in sepsis. In a retrospective study of 589 septic patients with hypotension in an urban tertiary care center ED, we developed a multi-variable model that distinguishes between patients who did and did not subsequently receive sustained (>24 h) vasopressor therapy. Candidate predictors were vital signs, intravenous fluid (IVF) volumes, laboratory measurements, and elapsed time from triage computed at timepoints leading up to the final decision timepoint of either vasopressor initiation or ED hypotension resolution without vasopressors. A model with six independently significant covariates (respiratory rate, Glasgow Coma Scale score, SBP, SpO2, administered IVF, and elapsed time) achieved a C-statistic of 0.78 in a held-out test set at the final decision timepoint, demonstrating the ability to reliably model usual care for vasopressor initiation for hypotensive septic patients. The included variables measured depth of hypotension, extent of disease severity and organ dysfunction. At an operating point of 90% specificity, the model identified a minority of patients (39%) more than an hour before actual vasopressor initiation, during which time a median of 2,250 (IQR 1,200–3,300) mL of IVF was administered. This single-center analysis shows the feasibility of a quantitative, objective tool for describing usual care. Dynamic practice models may help assess when management was atypical; such tools may also be useful for designing and interpreting clinical trials.
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Creative Commons Attribution 4.0 International license
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DOI of Published Version
10.3389/fmed.2022.715856
