(1461) Understanding Fluid and Vasopressor Decisions in Early Sepsis: A Randomized Vignette Survey

Introduction: Recent sepsis trials suggest that fluid-liberal vs fluid-restrictive, vasopressor-early resuscitation strategies have similar outcomes. However, little is known about how providers choose between fluids vs vasopressors.

Methods: We surveyed US ICU providers in the SCCM membership roster (12/2022). Each survey included 10 vignettes of patients with sepsis and hypotension. Clinical factors (e.g., fluid received, volume status) were randomized in each vignette. Respondents selected next management steps. We used logistic regression to test the impact of clinical factors on decision-making.

Results: Of 669 participants who reviewed the study information page, 550 (82.2%) completed at least 1 vignette and were included. Fluid volume received to-date had the largest impact on decision-making. Having received more than 1 liter (L) was associated with lower odds of prescribing fluid (2L: OR 0.3 [0.2-0.5], p< 0.001; 5L: OR 0.03 [0.02-0.05], p< 0.001) and higher odds of starting vasopressors (2L: OR 5.5 [3.8-8.0], p< 0.001; 5L: OR 22.3 [14.2-35.1], p< 0.001). Odds of giving fluid were also lower with volume overload on exam vs euvolemia (OR 0.30 [0.21-0.43], p< 0.001), 6L vs no oxygen requirement (OR 0.53 [0.35-0.79], p=0.002), and end-stage renal disease vs none (OR 0.68 [0.48-0.96], p=0.03). Conversely, odds of starting vasopressors increased with volume overload (OR 2.38 [1.5-3.8], p< 0.001), 6L oxygen need (OR 1.50 [1.02-2.21], p=0.04), rising vs stable lactate (OR 1.8 [1.2-2.6], p=0.005), and non-oliguric vs no acute kidney injury (OR 1.7 [1.1-2.5]. p=0.013). History of heart failure did not significantly impact decisions. Respondents started vasopressors through peripheral IVs (PIV) in 90.8% of cases. In cases where patients were already receiving peripheral norepinephrine, odds of recommending a central line increased with higher doses of norepinephrine (0.5 vs 0.08 mcg/kg/min: OR 13.7 [10.0-18.7], p< 0.001), escalating vs stable dosing (OR 2.9 [2.2-3.9], p< 0.001), and 24 vs 8 hour duration (OR 1.9 [1.5-2.3], p< 0.001).

Conclusions: In this survey of ICU providers, we identified key factors that influence fluid and vasopressor decisions. Most respondents chose to start vasopressors through PIVs, with vasopressor dose, trend, and duration impacting the subsequent decision to place a central line.