The Safety and Efficacy of Peripherally Administered Norepinephrine during the Perioperative Period

Intraoperative hypotension (IOH) is a highly prevalent adverse event associated with the induction and maintenance of general anesthesia. While the etiology of IOH is complex and multifactorial, hypotension most often occurs because anesthetic agents decrease vascular smooth muscle tone, impair myocardial contractility, and decrease levels of circulating catecholamines. The vasopressor drugs phenylephrine, norepinephrine (NE), and ephedrine have been traditionally used to counteract anesthesia-induced hypotension, with the sympathomimetic agent phenylephrine historically viewed as the first-line agent. However, NE may have a more advantageous clinical profile for treating hypotension by maintaining or increasing cardiac output and restoring decreased concentrations of circulating catecholamines. Yet despite these advantages, concerns of the safety of peripherally administered NE have limited its use to specific clinical settings such as central line in situ. Recent bench and clinical research examining the efficacy and safety profile of peripherally administered NE indicates that this stigma bears reexamination. Data from human and animal studies suggest that the peripheral administration of NE for the treatment of IOH may not only be acceptable, but in many cases, may be the best option.