Early hemodynamic changes after the use of push-dose noradrenaline in patients presenting to the emergency department...

Although continuous noradrenaline infusion (CNI) is standard vasopressor therapy during the initial resuscitation of patients with septic shock, hemodynamic stabilization may not be immediate. Push-dose noradrenaline (PDNA) has been proposed as a temporary measure while CNI is being established. However, its clinical use, dosing, early hemodynamic response, and short-term safety in the emergency department (ED) are not well described.

To address this gap, we conducted a single-center retrospective descriptive study at a tertiary care hospital in Japan in 2019. Adults with Sepsis-3 septic shock who received PDNA in the ED and were admitted to the intensive care unit were included. We assessed the context and dosing of PDNA administration, CNI use, mean arterial pressure (MAP) within 15 min after PDNA administration, and adverse events.

Of 91 patients with septic shock, 50 (55%) received PDNA. PDNA was administered at CNI initiation in 25 patients, during CNI dose escalation in 6, and as rescue administration before CNI initiation in 19. The median (interquartile range [IQR]) initial PDNA dose was 20 (20-30) µg. During the 15-minute observation window, 32 (64%) patients received one bolus, 14 (28%) received two, 3 (6%) received three, and 1 (2%) received four. The directly observed median (IQR) MAP was 52 (44-61) mmHg at initial PDNA administration (n = 30) and 62 (50-68) mmHg 1 min later (n = 25). One of 36 patients evaluable for prespecified physiological adverse events experienced an adverse event; however, no serious adverse events were documented.

In this single-center retrospective descriptive study, PDNA was most commonly administered at CNI initiation, and administration was followed by an early increase in median MAP. However, the noncomparative design and concurrent resuscitative interventions preclude attribution of this change solely to PDNA administration. No serious adverse events were documented; however, safety assessment was limited owing to missing data and retrospective ascertainment. These findings do not establish the effectiveness or safety of PDNA. Prospective comparative studies with standardized monitoring are required.