Let's continue our week dedicated to vasoactive agents with the background and evidence for NE in #septicshock Through its alpha-adrenergic mediated effects, NE is able to increase pre load and SVR in pts who are pre-load responsive, which is common in early sepsis.
NE can also improve microcirculation when administered early. Increasing MAP in septic shock pts with severe hypotension improved microvascular blood flow in pressure-dependednt vascular beds, improving tissue oxygenation pubmed.ncbi.nlm.nih.gov/20689910/
NE is considered the 1st line pressor for its alpha-adrenergic mediated effects (increase SVR). Compared to dopamine, there was no diff in mortality, but dopamine had more adverse events (mainly arrhythmias) nejm.org/doi/full/10.10…)
Compared to vasopressin, there was also no diff in mortality, but adding vasopressin allowed for reduction of the NE infusion dose, also decreasing mainly its ischemic side effects.
nejm.org/doi/full/10.10…
nejm.org/doi/full/10.10…
Side note: discontinuing NE prior to vasopressin during recovering septic shock resulted in less significant hypotension, but no diff in mortality. Also, vasopressin is titratable (some shops don't titrate it) accpjournals.onlinelibrary.wiley.com/doi/10.1002/ph…
Back to NE: early septic shock guidelines recommended fluid resus before considering starting pressors. But vasodilation is not corrected with fluids, amirite?
Permpikul et al found out that early (before receiving 30cc/KG of fluid resus) admin of NE was associated with increased shock control by 6hours of presentation. atsjournals.org/doi/pdf/10.116…
atsjournals.org/doi/10.1164/rc…
atsjournals.org/doi/10.1164/rc…
In summary: NE is your first line pressor for septic shock, use it early, add vasopressin if your NE dose is going up quickly. Thank you for following! journals.lww.com/co-criticalcar….
