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.
Am J Crit Care. 2023;32(2):127-130. © 2023 American Association of Critical-Care Nurses