Background & Objectives:

"Hemorrhagic shock is not a very rare occurrence in big hospitals. It might be encountered in the emergency room (ER) or in the operating rooms (OR). A rapid response and systematic management will save the life of the victim. The objective of this research was to investigate the impact of a low dose of norepinephrine (NE) administered prior to the initiation of hypotensive resuscitation in patients with hemorrhagic shock."

Methodology:

"This randomized controlled trial was conducted on 200 participants, at least 18 years old, classified as severely traumatized and had significant hemorrhage with mean arterial pressure ranging from 65 to 75 mmHg. We divided the patients into two equal groups. Group I received a low dose of NE (< 0.3 µg/kg/min) concurrently with resuscitation fluids. Group II received resuscitative fluids only. If the resuscitative fluids failed to keep mean arterial pressure (MAP) > 65 mmHg, the patient was progressively administered NE even with high doses (0.05 to more than 0.3 µg/kg/min). The primary outcome was 24-hour mortality. In-hospital mortality, incidence of acute kidney injury (AKI), and duration of hospital and intensive care unit (ICU) stay constituted the secondary outcomes."

Results:

"Group I had lower 24-hour mortality compared to Group II (3% vs 13%; P < 0.05). Compared to Group II, Group I needed reduced amount of fluid resuscitation within 24 h, had lower serum lactate levels at 6 and 12 h, and lower serum creatinine at 6, 12, and 18 h (P < 0.001). Group I had a lower incidence of mechanical ventilation (13% vs 27%), hospital and ICU stays, and in-hospital mortality (9% vs 21%) (P < 0.05). There was a lack of disparity seen in the incidence of AKI and duration of mechanical ventilation."

Conclusion:

"Low-dose norepinephrine infusion during the early period of hypotensive resuscitation reduces resuscitative fluid requirement, improves tissue perfusion, preserves renal function, and lowers mortality in hemorrhagic shock patients."

Exerpts:

Early administration of vasopressors may have deleterious circulatory effects in comparison to the use of fluids for resuscitation alone, as demonstrated by a prior study.
the number of packed RBCs, plasma, and platelet units transfused was not significantly different between the two groups. This observation implies that the continuous low-dose norepinephrine strategy did not compromise the need for blood product transfusions,
The total dose of NE administered within 24 was significantly lower in Group I compared to Group II (P <0.001).
Significantly lower serum lactate levels observed in Group I at 6 and 12h suggest that the continuous low-dose NE strategy facilitated improved tissue perfusion and more efficient clearance of lactate
the need for mechanical ventilation, ICU stay, 24-h mortality, and in-hospital mortality were significantly lower in Group I compared to Group II. These findings suggest that the continuous low-dose NE strategy employed in Group I may have contributed to improved clinical outcomes and reduced resource utilization.

Citation

Mohamed RM, Anwar AG, Eid AA. The effect of using low dose norepinephrine before hypotensive resuscitation in hemorrhagic shock; a randomized controlled trial. Anaesth. pain intensive care 2024;28(5):914−921; DOI: 10.35975/apic.v28i5.2560

Article Link

The effect of using low dose norepinephrine before hypotensive resuscitation in hemorrhagic shock; a randomized controlled trial

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