Extubation of Patients Receiving Vasopressor Infusions

In This Article

Abstract and Introduction

Abstract

Current guidelines recommend extubation only if a patient is not receiving vasopressor therapy or is receiving minimal doses of vasopressors. However, recent data indicate that extubation of patients receiving higher vasopressor doses may be safe. This study was undertaken to examine practices regarding extubation of patients receiving vasopressor therapy reported by clinician respondents to a survey by the Michigan Health and Hospital Association Keystone Center. One-third of respondents indicated that they would extubate a patient receiving vasopressors, and one-quarter indicated that it depended on the agent used, but more than half reported that their unit did not have a vasopressor use protocol or they did not know whether it did. Practices regarding extubation of patients receiving vasopressor therapy differed significantly by unit type and by role as a direct care provider. These data indicate that patient and clinician factors may drive practice patterns. Additional research to inform guidelines and local protocols is warranted.

Introduction

Prolonged mechanical ventilation is associated with negative outcomes, including increased risks of functional and cognitive impairment.^[1] Thus, liberating patients from mechanical ventilation as soon as it is safe to do so is central to high-quality critical care. Current clinical guidelines recommend hemodynamic stability (ie, low-dose or no vasopressor therapy) as a criterion for extubation.^[2]

In fact, safety screenings used to assess a patient's readiness for extubation identify significant vasopressor therapy (defined as dopamine or dobutamine at ≥5 μg/kg/min, norepinephrine at ≥2 μg/min, or vasopressin or milrinone at any dose) as a contraindication to a spontaneous breathing trial.^[3] In practice, however, most clinicians find extubation of patients receiving low-dose vasopressor therapy (ie, ≤0.1 μg/kg/min) to be acceptable.^[4] Studies have indicated that patients extubated while receiving low-dose vasopressor therapy have lower mortality,^[5] shorter hospital stays,^[5,6] and less time receiving mechanical ventilation6 than those extubated after discontinuation of vasopressor therapy. However, these same studies show that extubation of patients receiving high-dose vasopressor therapy may be associated with increased risk of adverse outcomes.^[5,6]

The lack of clarity about the safety of extubation of patients receiving vasopressor therapy may cause patients to undergo mechanical ventilation for longer than necessary, subjecting them to increased risk of harm and negative long-term outcomes. Moreover, little has been published on actual clinical practice patterns and whether protocols exist to guide extubation of patients receiving vasopressor therapy in intensive care units (ICUs) in the United States. To shed light on this issue, we analyzed data on practice patterns regarding extubation of patients receiving vasopressor therapy reported by clinicians who responded to a 2017 ICU survey conducted by the Michigan Health and Hospital Association (MHA) Keystone Center.

Table. Practice patterns of extubation of patients receiving vasopressor therapy by type of intensive care unit and direct patient care role (n = 128)
Survey question	Type of intensive care unit^a					Provides patient care at least 50% of the time^b (n = 40)
Survey question	Medical (n = 47)	Surgical (n = 18)	Mixed (n = 29)	Cardiac (n = 9)	Trauma (n = 1)	Provides patient care at least 50% of the time^b (n = 40)
Extubation of patients receiving vasopressors, No. (%) of respondents
Yes	12 (26)	12 (67)	12 (41)	4 (44)	1 (100)	16 (40)
No	8 (17)	0 (0)	4 (14)	4 (44)	0 (0)	9 (23)
Depends	14 (30)	5 (28)	8 (28)	1 (11)	0 (0)	13 (33)
Don't know	11 (23)	0 (0)	5 (17)	0 (0)	0 (0)	2 (5)
Protocol for vasopressor use, No. (%) of respondents
Yes	15 (32)	7 (38)	6 (21)	3 (33)	1 (100)	13 (33)
No	14 (30)	8 (44)	16 (55)	4 (44)	0 (0)	15 (38)
Don't know	16 (34)	2 (11)	7 (24)	2 (22)	0 (0)	12 (30)

^aSignificant differences for first question by Fisher exact test (P = .001). Percentages may not total 100 because of missing responses on some items.
^bSignificant differences for first question by Fisher exact test (P = .01). Because of rounding, percentages may not total 100.

Supplemental Table 1. Characteristics of 128 respondents
Characteristic	No. (%) of respondents^a
Professional role
Staff nurse	33 (26)
Nurse manager	31 (24)
Nurse educator/clinical nurse specialist	12 (9)
Respiratory therapist	4 (3)
Physician, nurse practitioner, or physician assistant	3 (2)
Administrator	4 (3)
Other	27 (21)
Type of intensive care unit
Medical	47 (37)
Surgical	18 (14)
Cardiac	9 (7)
Trauma	1 (1)
Mixed	37 (29)
Direct patient care at least 50% of the time	40 (31)

^aPercentages may not total 100 because of missing responses on some items.

Supplemental Table 2. Practice patterns of extubation of patients receiving vasopressor therapy (n = 128)
Practice	No. (%) of respondents^a
Extubation of patients receiving vasopressors
Yes	41 (32)
Depends	29 (23)
No	16 (13)
Don't know	22 (17)
Protocol for vasopressor use and extubation
Yes	34 (27)
No	43 (34)
Don't know	31 (24)
Which vasopressors will you extubate on? (n = 70)^b
Dobutamine	1 (1)
Dopamine	10 (14)
Phenylephrine	2 (3)
Norepinephrine	20 (29)
Vasopressin	29 (41)
Epinephrine	2 (3)
Other	1 (1)
Dose or physician dependent	4 (6)
All	1 (1)
Clinicians involved in decision to extubate (n = 99)
Nurse	99 (100)
Physician	99 (100)
Respiratory therapist	99 (100)
Nurse practitioner or physician assistant	8 (8)
Clinical nurse specialist or educator	8 (8)

^aNumbers and sample size vary owing to skip logic and missing responses. Percentages may not total 100 because of missing responses on some items.
^bThe 70 respondents who indicated "yes" or "depends" for extubation of patients receiving vasopressors were asked "which vasopressors will you extubate on?"