| Background Therapy with vasoactive agents, including vasopressors, inotropes and vasodilators, is prescribed to correct abnormal vascular tone, and/or to improve cardiac output (CO) in order to restore tissue perfusion and normalize oxygen consumption. Currently, this therapy is considered basic management practice in the care of patients with shock in intensive care units (ICU). However, previous surveys have suggested that inconsistencies in the use of vasoactive agents existed among ICU physicians, even in Europe or North America. One reason for this inconsistency is that the optimal selection and titration of vasoactive agents to treat shock, especially vasopressors, still remains debatable. In addition, compliance with the Surviving Sepsis Campaign’s resuscitation and management bundles including use of vasopressors, reported by a prospective cohort study, is poor, and differences existed among different countries or regions. There are no published reports about vasoactive agent titration strategies by Chinese ICU physicians caring for clients with shock.Objectives This study was conducted to include questions on the selection of vasoactive agents, management during the use of vasoactive agent therapy, monitoring protocols when using these agents, and demographic characteristics of Chinese physicians in ICUs nationwide.Methods A nationwide survey of physicians was conducted. The survey protocol was used according to the published recommendations for survey methodology. A questionnaire was developed after reviewing previous surveys about the use of vasoactive agents and a review of the guidelines for vasoactive agent therapy in the treatment of septic, hypovolemic and cardiogenic shock. Focus groups were used to review and refine the questionnaire. It consisted of 26 questions and was divided into 4 parts. A core group of physician coordinators were selected from the Chinese Society for Critical Care Medicine. This group was selected because they represent 31 regions or provinces in mainland China. The coordinators were asked to contact physicians they knew and/or who cared for critically ill adults in an ICU located in their region or province about participation in this study. The coordinators sent the questionnaire via email to potential participants. Completed questionnaires were then returned to the coordinators and forwarded to the authors of this study.Results The response rate was 65.1% with physicians returning 586 valid questionnaires.Norepinephrine was the first choice of a vasopressor used to treat septic shock by 70.8% of respondents; 73.4% of respondents favored dopamine for hypovolemic shock; and 68.3% of respondents preferred dopamine for cardiogenic shock. Physicians working in teaching hospitals preferred norepinephrine for management of all types of shock at a statistically significant higher rate than physicians working in non-teaching hospitals. Yet, physicians from non-teaching hospitals preferred dopamine as their first choice of vasopressors. A statistically significant difference was not found between senior and junior physicians related to the first choice of vasopressors.All participants reported their first choice of inotropes for management of septic and cardiogenic shock, but 54.7%(321/586) reported they also used these agents in management of hypovolemic shock. Dobutamine was selected by 84.1%,64.5% and 60.6% of respondents for septic, hypovolemic and cardiogenic shock, respectively. A statistically significant larger percentage of physicians choosing dobutamine were from teaching hospitals as compared to physicians from non-teaching hospitals. A statistically significant higher percentage of physicians choosing dobutamine were from teaching hospitals as compared to physicians from non-teaching hospitals. Following dobutamine, digitalis was the second agent most often selected by physicians. It was selected more often for management of cardiogenic shock (29.7%, 174/586) than for hypovolemic (27.7%,89/321) or septic shock (11.9%,70/586). The percentage of physicians from non-teaching hospitals choosing digitalis to treat all forms of shock was significantly higher than physicians from teaching hospitals. A significant difference in the first choice of inotropes was not found between senior and junior physicians.Vasodilator agents were prescribed by physicians in the management of cardiogenic shock (67.1%) rather than for septic (32.3%) and hypovolemic shock (6.5%). However, a significantly higher percentage of junior physicians, and physicians from non-teaching hospitals reported no use of vasodilators in management of shock. In addition, the most commonly used vasodilators were nitroglycerine (71.2%,417/586), sodium nitroprusside (45.6%,267/586) and phentolamine (32.9%,193/586). There was no significant difference in the choice of vasodilators between physicians from teaching and non-teaching hospitals. But, when compared with senior physicians, a significantly low percentage of junior physicians used each of the vasodilators for management of shock.Nearly half of respondents believed that the mean arterial pressure (MAP) target for maintenance of vasopressor therapy were the same among the different forms of shock. The percentage of physicians from non-teaching hospitals who answered "yes" for MAP target to this item on the questionnaire was statistically significant when compared with physicians from teaching hospitals who answered "yes" to this same item. The target MAP was 64.3 ±7.5mmHg for maintaining vasopressor therapy to treat septic shock. A higher mean (SD) value of MAP target for maintaining vasopressor therapy to treat septic shock was preferred by physicians from teaching hospitals and this was statistically significant when compared with physicians from non-teaching hospitals. But, no statistical differences were found between junior and senior physicians related to the target MAP target for maintaining vasopressor therapy.The primary indications were hypotension (80.2%,470/586), low cardiac output/cardiac index (CO/CI) (66.4%,389/586), cold extremities (37%,217/586) and oliguria (30.9%,181/586). Parameters used for endpoints included MAP (86.7%, 508/586), urine output (58.9%,345/586), CO/CI (50.2%,294/586) and blood lactate concentration (40.8%,239/586). The percentage of physicians from teaching hospitals who selected a low CO/CI as the indication was significantly higher than physicians from non-teaching hospitals. Oliguria was selected by more physicians from non-teaching hospitals. Urine output was the only parameter used for the endpoint of inotropic therapy with a greater difference in percentages of physicians from teaching and non-teaching hospitals. There were no differences between senior and junior physicians in the percentages of selecting both the indications and parameters used for endpoints for inotropic therapy.Some participants (28.3%,166/586) indicated their preference for low-dose dopamine in management of shock to improve renal function. The percentage of participants from non-teaching hospitals was higher (35.6%,68/191) than from teaching hospitals (24.8%,98/395) and statistically significant. When comparing junior physicians (30.2%,102/338) with senior physicians (25.8%,64/248) regarding the use of low-dose dopamine, a higher percentage was reported but this was not statistically significantThe items on the questionnaire related to routine and advanced monitoring devices/parameters were in multiple response format. All respondents reported that they used electrocardiograph, noninvasive blood pressure, pulse oximetry and temperature as routine hemodynamic monitoring practices. Other frequently used monitoring devices/parameters included blood gas analysis (98.5%,577/586), central venous pressure (87.9%,515/586), blood lactate concentration (84.6%,496/586) and invasive blood pressure (IBP) (44.2%,259/586).Advanced monitoring devices/parameters were investigated in this survey. The most often used was pulse index contour continuous cardiac output (PICCO) chosen by 26.8%(106/395) of respondents from teaching hospitals and 14.7%(28/191) in non-teaching hospitals. Other advanced monitoring devices/parameters, including pulmonary artery catheter (PAC), transesophageal echocardiography gastric mucosal microcirculatory monitoring and sublingual microcirculatory monitoring, were chosen by less than 5% of respondents. There was no statistically significant difference between senior and junior physicians. PICCO and PAC were used more often in teaching hospitals than in non-teaching hospitals.Conclusions In conclusion, discrepancies exist in the use of vasoactive agent therapy by Chinese physicians in intensive care settings. It appears that the majority of Chinese physicians in ICUs follow the recommended guidelines related to the first-line choice of vasoactive agents when managing patients with septic shock. But, the rate of compliance with first-line vasoactive agent therapy when managing patients with hypovolemic and cardiogenic show is very low. Both senior and junior physicians in non-teaching hospitals are more apt to select inappropriate choices about the use of vasoactive medications than the same groups of physicians from teaching hospital ICUs. These research findings suggest that physicians lack information on the evidence-based guidelines for management of clients in shock and this contributed to varied practices in the selection and titration of vasoactive agents. As a result, education resources and programs about vasoactive therapy in shock management are suggested for all physicians. |
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