Episode 135: A Case For Low Dose Norepinephrine

In this 135th episode I discuss my argument for using low dose norepinephrine to treat or even prevent hypotension in the OR and ICU. I discuss the CENSER trial looking at early norepinephrine in sepsis as well as a paper looking at preemptive norepinephrine in open cystectomies and a review article of trials looking at pressor use in free flap surgery. Join in the conversation here with your comments and on the ACCRAC Facebook page and Twitter @accracpodcast and @jwolpaw.

References:

CENSER: https://www.atsjournals.org/doi/full/10.1164/rccm.201806-1034OC

Cystectomies: https://www.ncbi.nlm.nih.gov/pubmed/24012203

Free Flaps: https://www.ncbi.nlm.nih.gov/pubmed/26340760

7 Replies to “Episode 135: A Case For Low Dose Norepinephrine”

  1. Jed — great Podcast and review of the CENSER trial! I am a big fan of starting norepinephrine early. I actually prefer a norepinephrine infusion over a phenylephrine infusion during intraoperative care (I am a general anesthesiologist). I think something that did not come up in your Podcast is the role of norepinephrine to combat vasoplegia in the setting of ACEi/ARB use. I certainly acknowledge vasopressin works well for this too. I suspect reaching for norepi over a phenylephrine infusion as a routine practice is perfectly safe — and perhaps (probably) more effective.

    To play devil’s advocate — I could not find any head to head literature of phenylephrine vs. norepinephrine in otherwise healthy, not septic, intraoperative patients. The exception being one paper focusing on spinal anesthesia. Dr. Berend Mets wrote a nice review in 2016 in A&A asking this very same question. I know where I practice (NW Pennsylvania) the culture is to first reach for phenylephrine and then norepinephrine. Does this matter? Can we improve outcomes? I think you make excellent points from a physiologic and pharmacologic standpoint — but I do not think this has played out in the intraoperative literature — at least not yet!

    Great Podcast and review!!

  2. Generally

    I just don’t see the point of phenylephrine except for cases where you want the pure alpha effect, lower heart rate and lower CO, which elude me just now (severe aortic stenosis ??) .

    This is what worries me a bit:

    Br J Anaesth. 2012 May; 108(5): 815–822.
    Published online 2012 Mar 4. doi: 10.1093/bja/aes023

    Br J Anaesth. 2011 Aug;107(2):209-17. doi: 10.1093/bja/aer150. Epub 2011 Jun 3.

    On a more general note I think that RCT’s are wonderful things, but in this case I think the physiology is less likely to lead you astray than a group effect with possible limited generalisability.

    1. Great points, totally agree with you. I think a lot of practitioners are more comfortable with phenylephrine because for a long time it wasn’t thought to be safe to use norepinephrine peripherally and it’s very hard to change old habits.

  3. Great podcast as always! I thought the CENSER trial was really interesting for a lot of reasons as well. I just heard about an ongoing trial (CLOVERS https://clinicaltrials.gov/ct2/show/NCT03434028) that is based on a similar paradigm…basically comparing early fluids with rescue pressors vs early pressors with rescue fluids in septic patients. Can’t wait for the results!

    -Leif, CA-3 Resident

  4. Jed,

    Love the podcast (have highly recommended it to my residents), and this is a particularly provocative episode and a reason that anesthesiologists need to be on committees that make hospital policy. Re: the head-to-head trial you were seeking in the podcast:

    Plast Reconstr Surg. 2016 Jun;137(6):1016e-23e.

    I trained at a program where the surgeons were militant about no pressors and after graduating, I ran across this article when I was reviewing this topic with my residents. It seems so counterintuitive to give liter after liter of crystalloid/colloid (causing significant venous congestion) to these patients to try to maintain BP as opposed to using a low-dose pressor. My wife is an ENT, and we have occasional dinner-table discussions about this also. Anyway, I think there is enough evidence on our side to support low-dose vasopressors, and I thank you for discussing this very interesting topic.

    Keep up the great work!

    1. Thanks Eric! I hadn’t seen that paper but certainly supports what I think makes sense and what the other literature suggests so thanks for sharing!

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.