Intensity of Vasopressor Therapy and In-Hospital Mortality for Infants and Children: An Opportunity for Counseling Families.

CONTEXT: Most pediatric deaths occur in an intensive care unit, and treatment specific predictors of mortality could help clinicians and families make informed decisions.

OBJECTIVE: To investigate whether the intensity of vasopressor therapy for pediatric patients, regardless of diagnosis, predicts in-hospital mortality.

METHODS: Single-center, retrospective medical chart review of children aged 0-17 who were admitted between 2005 and 2015 at a pediatric tertiary care center in the U.S. and received any vasopressor medication-dopamine, dobutamine, epinephrine, vasopressin, norepinephrine, or hydrocortisone.

RESULTS: During the 10-year period, 1654 patients received at least one vasopressor medication during a hospitalization. Median age at the time of hospitalization was three months, and the median duration of hospitalization was 23 days; 8% of patients had two to five hospitalizations in which they received vasopressors. There were 176 total patients who died while receiving vasopressors; most (93%) died during their first hospitalization. The most common diagnosis was sepsis (34%), followed by congenital heart disease (17%). Dopamine was the most commonly prescribed first-line vasopressor (70%), and hydrocortisone was the most commonly prescribed second-line vasopressor (49%) for all pediatric patients. The incidence of mortality rose sequentially with escalating vasopressor support, increasing from under 10% with the first vasopressor to 48% at the maximum number of agents. The odds of death almost doubled with the addition of each new vasopressor.

CONCLUSIONS: The intensity of vasopressor therapy for pediatric patients, regardless of diagnosis, is associated with in-hospital mortality; vasopressor escalation should trigger intensive palliative care supports.