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BMC Anesthesiology
Published in: BMC Anesthesiology 1/2023

Open Access 01-12-2023 | Hypotension | Research

Micro- and macrocirculatory effects of norepinephrine on anaesthesia-induced hypotension: a prospective preliminary study

Authors: Manuel Kindermans, Jona Joachim, Elsa Manquat, Charlotte Levé, Alex Hong, Joachim Mateo, Alexandre Mebazaa, Etienne Gayat, Daniel De Backer, Fabrice Vallée

Published in: BMC Anesthesiology | Issue 1/2023

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Abstract

Background

Intraoperative arterial hypotension (IOH) leads to increased postoperative morbidity. Norepinephrine is often use to treat IOH. The question regarding the mode of administration in either a bolus or continuous infusion remains unanswered. The aim of the present study was to describe and compare the effects on macrocirculation and microcirculation of a bolus and a continuous infusion of norepinephrine to treat IOH.

Methods

We conducted a prospective observational study with adult patients who underwent neurosurgery. Patients with invasive arterial blood pressure and cardiac output (CO) monitoring were screened for inclusion. All patients underwent microcirculation monitoring by video-capillaroscopy, laser doppler, near-infrared spectroscopy technology, and tissular CO2. In case of IOH, the patient could receive either a bolus of 10 µg or a continuous infusion of 200 µg/h of norepinephrine. Time analysis for comparison between bolus and continuous infusion were at peak of MAP. The primary outcome was MFI by videocapillaroscopy.

Results

Thirty-five patients were included, with 41 boluses and 33 continuous infusion.
Bolus and continuous infusion induced an maximal increase in mean arterial pressure of +30[20-45] and +23[12-34] %, respectively (P=0,07). For macrocirculatory parameters, continuous infusion was associated with a smaller decrease in CO and stroke volume (p<0.05).
For microcirculatory parameters, microvascular flow index (-0,1 vs. + 0,3, p=0,03), perfusion index (-12 vs. +12%, p=0,008), total vessel density (-0,2 vs. +2,3 mm2/mm2, p=0,002), showed significant opposite variations with bolus and continuous infusion, respectively.

Conclusions

These results on macro and microcirculation enlighten the potential benefits of a continuous infusion of norepinephrine rather than a bolus to treat anaesthesia-induced hypotension.

Trial registration

(NOR-PHARM: 1-17-42 Clinical Trials: NCT03454204), 05/03/2018
Literature
1.
Walsh, et al. Relationship between Intraoperative Mean Arterial Pressure and Clinical Outcomes after Noncardiac SurgeryToward an Empirical Definition of Hypotension. Anesthesiology. 2013;119(3):507–15.
2.
Bijker JB, van Wolfswinkel L. Intraoperative hypotension and 1-year mortality after noncardiac surgery. Anesthesiology. 2009;111(6):1217–26.
3.
Monk TG, Mangione MP, Nguyen JD, Hammermeister KE. Association between Intraoperative Hypotension and Hypertension and 30-day Postoperative Mortality in Noncardiac Surgery. Anesthesiology. 2015;123(2):307–19.
4.
Hoka S, Yamaura K, Takenaka T, Takahashi S. Propofol-induced Increase in vascular capacitance is due to inhibition of sympathetic vasoconstrictive activity. Anesthesiology. 1998;89(6):1495–500.CrossRefPubMed
5.
Koch M, De Backer D, Vincent JL, Barvais L, Hennart D, Schmartz D. Effects of propofol on human microcirculation. Br J Anaesthesia. 2008;101(4):473–8.CrossRef
6.
Mets B. Should Norepinephrine, Rather than Phenylephrine, Be Considered the Primary Vasopressor in Anesthetic Practice? Anesth Analg. 2016;122(5):1707–14.CrossRefPubMed
7.
Vallée F, Passouant O, Le Gall A, Joachim J, Mateo J, Mebazaa A, et al. Norepinephrine reduces arterial compliance less than phenylephrine when treating general anesthesia-induced arterial hypotension. Acta Anaesthesiologica Scandinavica. 2017;61(6):590–600.CrossRefPubMed
8.
Futier E, Lefrant JY, Guinot PG, Godet T, Lorne E, Cuvillon P, et al. Effect of individualized vs standard blood pressure management strategies on postoperative organ dysfunction among high-risk patients undergoing major surgery: a randomized clinical trial. JAMA. 2017;318(14):1346.CrossRefPubMedPubMedCentral
9.
Kee WDN, Lee SWY, Tan PE, Phil M, Khaw KS. Randomized double-blinded comparison of norepinephrine and phenylephrine for maintenance of blood pressure during spinal anesthesia for cesarean delivery. Anesthesiology. 2015;122(4):736–45.
10.
Ngan Kee WD, Lee SWY, Ng FF, Lee A. Norepinephrine or phenylephrine during spinal anaesthesia for Caesarean delivery: a randomised double-blind pragmatic non-inferiority study of neonatal outcome. Br J Anaesth. 2020;125(4):588–95.CrossRefPubMed
11.
Vallée F, Le Gall A, Joachim J, Passouant O, Matéo J, Mari A, et al. Beat-by-beat assessment of cardiac afterload using descending aortic velocity–pressure loop during general anesthesia: a pilot study. J Clin Monit Comput. 2018;32(1):23–32.CrossRefPubMed
12.
Siegenthaler N, Giraud R, Piriou V, Romand JA, Bendjelid K. Altérations de la microcirculation dans les états de choc: physiopathologie, surveillance et traitement. Annales Françaises d’Anesthésie et de Réanimation. 2010;29(2):135–44.CrossRefPubMed
13.
Poterman M, Vos JJ, Vereecke HEM, Struys MMRF, Vanoverschelde H, Scheeren TWL, et al. Differential effects of phenylephrine and norepinephrine on peripheral tissue oxygenation during general anaesthesia: a randomised controlled trial. Eur J Anaesthesiol. 2015;32(8):571–80.CrossRefPubMed
14.
De Backer D, Donadello K, Sakr Y, Ospina-Tascon G, Salgado D, Scolletta S, et al. Microcirculatory alterations in patients with severe sepsis: impact of time of assessment and relationship with outcome*. Crit Care Med. 2013;41(3):791–9.CrossRefPubMed
15.
De Backer D, Creteur J, Dubois MJ, Sakr Y, Vincent JL. Microvascular alterations in patients with acute severe heart failure and cardiogenic shock. Am Heart J. 2004;147(1):91–9.CrossRefPubMed
16.
Trzeciak S, McCoy JV, Phillip Dellinger R, Arnold RC, Rizzuto M, Abate NL, et al. Early increases in microcirculatory perfusion during protocol-directed resuscitation are associated with reduced multi-organ failure at 24 h in patients with sepsis. Intensive Care Med. 2008;34(12):2210–7.CrossRefPubMedPubMedCentral
17.
Kim TK, Cho YJ, Min JJ, Murkin JM, Bahk JH, Hong DM, et al. Microvascular reactivity and clinical outcomes in cardiac surgery. Crit Care. 2015;19(1):316.CrossRefPubMedPubMedCentral
18.
Losser MR, Payen de la Garanderie D. Évaluation de la microcirculation en pratique clinique. Anesthésie Réanimation. 2019;5(3):193‑9.
19.
Bouattour K, Teboul JL, Varin L, Vicaut E, Duranteau J. Preload dependence is associated with reduced sublingual microcirculation during major abdominal surgery. Anesthesiology. 2019;130(4):541–9.CrossRefPubMed
20.
Dubin A, Pozo MO, Casabella CA, Pálizas F, Murias G, Moseinco MC, et al. Increasing arterial blood pressure with norepinephrine does not improve microcirculatory blood flow: a prospective study. Critical Care. 2009;13(3):R92.CrossRefPubMedPubMedCentral
21.
Jhanji S, Stirling S, Patel N, Hinds CJ, Pearse RM. The effect of increasing doses of norepinephrine on tissue oxygenation and microvascular flow in patients with septic shock*. Crit Care Med. 2009;37(6):1961–6.CrossRefPubMed
22.
Fiorese Coimbra KT, de Freitas FGR, Bafi AT, Pinheiro TT, Nunes NF, de Azevedo LCP, et al. Effect of increasing blood pressure with noradrenaline on the microcirculation of patients with septic shock and previous arterial hypertension. Crit Care Med. 2019;47(8):1033–40.CrossRefPubMed
23.
Vallée F, Nougué H, Mari A, Vodovar N, Dubreuil G, Damoisel C, et al. Variations of cutaneous capnometry and perfusion index during a heating challenge is early impaired in septic shock and related to prognostic in non-septic shock. Shock. 2019;51(5):585–92.
24.
Hong A, Joachim J, Buxin C, Levé C, Le Gall A, Millasseau S, et al. Using velocity-pressure loops in the operating room: a new approach of arterial mechanics for cardiac afterload monitoring under general anesthesia. Am J Physiol-Heart Circulatory Physiol. 2019;317(6):H1354–62.CrossRef
25.
On behalf of the Cardiovascular Dynamics Section of the ESICM, Ince C, Boerma EC, Cecconi M, De Backer D, Shapiro NI, et al. Second consensus on the assessment of sublingual microcirculation in critically ill patients: results from a task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2018;44(3):281–99.CrossRef
26.
Mari A, Nougue H, Mateo J, Vallet B, Vallée F. Transcutaneous PCO2 monitoring in critically ill patients: update and perspectives. J Thorac Dis. 2019;11(Suppl 11):S1558–67.CrossRefPubMedPubMedCentral
27.
Bezemer R, Lima A, Myers D, Klijn E, Heger M, Goedhart PT, et al. Assessment of tissue oxygen saturation during a vascular occlusion test using near-infrared spectroscopy: the role of probe spacing and measurement site studied in healthy volunteers. Crit Care. 2009;13(Suppl 5):S4.CrossRefPubMedPubMedCentral
28.
Ferré F, Martin C, Bosch L, Kurrek M, Lairez O, Minville V. Control of spinal anesthesia-induced hypotension in adults. Local Reg Anesth. 2020;13:39–46.CrossRefPubMedPubMedCentral
29.
Ueda K, Janiczek DM, Casey DP. Arterial Stiffness Predicts General Anesthesia-Induced Vasopressor-Resistant Hypotension in patients taking angiotensin-converting enzyme inhibitors. J Cardiothorac Vasc Anesth. 2021;35(1):73–80.CrossRefPubMed
30.
Lionet L, Descamps R, Nguyen TM, Goyer I, Gerard JL. Utilisation de la noradrénaline très diluée au bloc opératoire : enquête de pratique et mise au point. Anesth Réanim. 2022;8(2):107–16.CrossRef
31.
Flick M, Briesenick L, Peine S, Scheeren TWL, Duranteau J, Saugel B. The effect of moderate intraoperative blood loss and norepinephrine therapy on sublingual microcirculatory perfusion in patients having open radical prostatectomy: an observational study. Eur J Anaesthesiol. 2021;38(5):459–67.CrossRefPubMed
32.
Cannesson M, Jian Z, Chen G, Vu TQ, Hatib F. Effects of phenylephrine on cardiac output and venous return depend on the position of the heart on the Frank-Starling relationship. J Appl Physiol. 2012;113(2):281–9.CrossRefPubMed
33.
Maas JJ, Pinsky MR, de Wilde RB, de Jonge E, Jansen JR. Cardiac output response to norepinephrine in postoperative cardiac surgery patients: interpretation with venous return and cardiac function curves. Crit Care Med. 2013;41(1):143–50.CrossRefPubMed
Metadata
Title
Micro- and macrocirculatory effects of norepinephrine on anaesthesia-induced hypotension: a prospective preliminary study
Authors
Manuel Kindermans
Jona Joachim
Elsa Manquat
Charlotte Levé
Alex Hong
Joachim Mateo
Alexandre Mebazaa
Etienne Gayat
Daniel De Backer
Fabrice Vallée
Publication date
01-12-2023
Publisher
BioMed Central
Published in
BMC Anesthesiology / Issue 1/2023
Electronic ISSN: 1471-2253
DOI
https://doi.org/10.1186/s12871-023-02342-3

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