Episode 27: Vasopressors for Hypotension During Anesthesia – Should We Be Less Pushy?



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Episode Summary

Anesthesia-induced hypotension is commonly treated with push dose vasopressors. Today we dive into what the newest evidence is showing us about the use of phenylephrine, ephedrine, and norepinephrine IV bolus doses. We talk about cerebral oxygen concentrations and cardiac output when administering these vasopressors and ultimately ask ourselves…should we be less pushy?


What You'll Learn

  1. Review usual practice standards for anesthesia-induced hypotension.
  2. Discuss the most commonly used push dose vasopressors.
  3. Examine the evidence comparing commonly administered vasopressors.
  4. Discuss the physiologic consequences of push dose vasopressor use.


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Recommended Resources

  1. Kee W, et al. Randomized double-blinded comparison of norepinephrine and phenylephrine for maintenance of blood pressure during spinal anesthesia for cesarean delivery. Anesthesiology. 2015 Apr;122(4):736-45
  2. Larson S, et al. Effect of phenylephrine on cerebral oxygen saturation and cardiac output in adults when used to treat intraoperative hypotension: a systematic review. BI Evid Synth. 2020 Sep 15;19(1):34-58
  3. Meng L, et al.. Effect of phenylephrine and ephedrine bolus treatment on cerebral oxygenation in anaesthetized patients. Br J Anaesth. 2011 Aug; 107(2): 209–217
  4. Mohta M, et al. Comparison of the potency of phenylephrine and norepinephrine bolus doses used to treat post-spinal hypotension during elective caesarean section. Int J Obstet Anesth. 2019 May;38:25-31
  5. Nissen P, et al. Phenylephrine but not ephedrine reduces frontal lobe oxygenation following anesthesia-induced hypotension. Neurocrit Care. 2010 Feb;12(1):17-23. 
  6. Pelaez A, et al. Effect of adrenergic agonists on coronary blood flow: a laboratory study in healthy volunteers. Physiol Rep. 2016 May;4(10):e12806
  7. Pancaro C, et al. Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study. Anesth Analg. 2020;131(4):1060-1065 
  8. Sharkey  A. Comparison of Intermittent Intravenous Boluses of Phenylephrine and Norepinephrine to Prevent and Treat Spinal-Induced Hypotension in Cesarean Deliveries: Randomized Controlled Trial. Anesth Analg. 2019 Nov;129(5):1312-1318. 
  9. Thiele R, et al. The physiologic implications of isolated alpha(1) adrenergic stimulation. Anesth Analg. 2011 Aug;113(2):284-96
  10. Vallee F, et al. Norepinephrine reduces arterial compliance less than phenylephrine when treating general anesthesia-induced arterial hypotension. Acta Anaesthesiol Scand. 2017 Jul;61(6):590-600
  11. Vanpeteghem C, et al. Ephedrine and phenylephrine induce opposite changes in cerebral and paraspinal tissue oxygen saturation, measured with near-infrared spectroscopy: a randomized controlled trial. J Clin Monit Comput. 2020 Apr;34(2):253-259
  12. Weiland NH, Cerebral oxygenation during changes in vascular resistance and flow in patients on cardiopulmonary bypass – a physiological proof of concept study. Anaesthesia. 2017, 72, 49–56
  13. Williams G, et al. Vasopressor treatment and mortality following nontraumatic subarachnoid hemorrhage: a nationwide electronic health record analysis. Neurosurg Focus. 48 (5):E4, 2020

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Podcast music by Eino Toivanen, kongano.com


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