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Interrogating a clinical database to study treatment of hypotension in the critically ill
  1. Joon Lee1,
  2. Rishi Kothari2,
  3. Joseph A Ladapo3,
  4. Daniel J Scott1,
  5. Leo A Celi1,4
  1. 1Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
  2. 2Mount Sinai School of Medicine, New York City, New York, USA
  3. 3New York University School of Medicine, New York City, New York, USA
  4. 4Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  1. Correspondence to Dr Joon Lee; joonlee{at}mit.edu

Abstract

Objective In intensive care, it is imperative to resolve hypotensive episodes (HEs) in a timely manner to minimise end-organ damage. Clinical practice guidelines generally recommend initial treatment with fluid resuscitation followed by vasoactive agent administration if patients remain hypotensive. However, the impact of such interventions on patient outcomes has not been clearly established. Hence, the objective of this study was to investigate the relationship between fluid and vasoactive agent interventions and patient outcomes, while highlighting the utility of electronic medical records in clinical research.

Design Retrospective cohort study.

Setting Intensive care units (ICUs) at a large, academic, tertiary medical center.

Participants Patients in Multi-parameter Intelligent Monitoring in Intensive Care II (a large electronic ICU database) who experienced a single HE during their ICU stay. 2332 patients had complete data.

Primary and secondary outcome measures The primary outcome of interest was inhospital mortality. Secondary outcomes were ICU length of stay (LOS), HE duration, Hypotension Severity Index (defined as the mean arterial pressure curve area below 60 mm Hg during the HE) and rise in serum creatinine.

Results Fluid resuscitation was associated with significantly shorter ICU LOS among ICU survivors (p=0.007). Vasoactive agent administration significantly decreased HE duration (p<0.001) and Hypotension Severity Index (p=0.002) but was associated with increased inhospital mortality risk (p<0.001), prolonged ICU LOS among ICU survivors (p=0.04) and rise in serum creatinine (p=0.002) after adjustment for confounders. Propensity score analyses as well as sensitivity analyses in treatment-, diagnosis- and ICU service-specific subpopulations corroborated the relationship between vasoactive agents and increased inhospital mortality.

Conclusions An adverse relationship between vasoactive agents and inhospital mortality was found in patients with hypotension. This study has implications for the care of critically ill patients with hypotension and illustrates the utility of electronic medical records in research when randomised controlled trials are difficult to conduct.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

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Footnotes

  • To cite: Lee J, Kothari R, Ladapo JA, et al. Interrogating a clinical database to study treatment of hypotension in the critically ill. BMJ Open 2012;2:e000916. doi:10.1136/bmjopen-2012-000916

  • Contributors JL designed the study, conducted data extraction and analyses and wrote most parts of the manuscript. RK designed the study, helped with data extraction and critically revised the manuscript. JAL wrote the discussion section and critically revised the manuscript. DJS helped with data extraction and critically revised the manuscript. LAC designed the study, wrote the discussion section and critically revised the manuscript. JL and LAC are the guarantors of the study. All authors had full access to all of the data.

  • Funding This research was supported by grant R01 EB001659 from the National Institute of Biomedical Imaging and Bioengineering (NIBIB) of the National Institutes of Health (NIH). JL also holds a Postdoctoral Fellowship from the Natural Sciences and Engineering Research Council of Canada.

  • Competing interests None.

  • Ethics approval The study used a public de-identified database and the IRB approval was waived.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement There is no additional data available. This study was conducted based on the public MIMIC-II database. Any interested researcher can gain access to MIMIC-II for details, please see http://physionet.org/mimic2/

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