Continuous versus bolus norepinephrine administration and arterial blood pressure stability during induction of general anaesthesia in high-risk....

Vokuhl C, Kouz K, Flick M, et al. Continuous versus bolus norepinephrine administration and arterial blood pressure stability during induction of general anaesthesia in high-risk noncardiac surgery patients: a randomised trial. Br J Anaesth. 2025. doi:10.1016/j.bja.2025.06.025

Summary

This randomized clinical trial compared the effects of continuous norepinephrine infusion versus intermittent manual bolus administration on arterial blood pressure stability during induction of general anesthesia in high-risk noncardiac surgical patients. Seventy-one patients were randomized, and blood pressure stability was measured as generalized average real variability of mean arterial pressure (ARV-MAP) during the first 15 minutes post-induction. The study found that continuous norepinephrine infusion significantly improved arterial blood pressure stability compared to bolus administration, suggesting it may be preferable in high-risk surgical patients.

Key Points

1. Clinical Significance of Post-Induction Hypotension: Post-induction hypotension is common in high-risk surgical patients and is linked to adverse outcomes such as acute kidney injury and increased morbidity, underscoring the clinical importance of maintaining stable hemodynamics during anesthetic induction.
2. Trial Design and Methods: This single-center randomized trial enrolled 72 adult patients scheduled for high-risk elective noncardiac surgery who were at least 45 years old, had ASA status II-IV, and required arterial blood pressure monitoring. Patients were randomized to continuous or bolus norepinephrine administration during anesthetic induction.
3. Measurement and Endpoint: The primary outcome, arterial blood pressure stability, was quantified as generalized ARV-MAP over a 15-minute period following anesthetic induction. This measure effectively captures the variability and stability of mean arterial pressure in real-time.
4. Improved Hemodynamic Stability: Continuous norepinephrine infusion resulted in significantly better blood pressure stability, with a mean ARV-MAP of 19 mmHg/min, compared to 25 mmHg/min in the bolus group, indicating more stable hemodynamics during a critical perioperative period.
5. Reduced Duration and Severity of Hypotension: Patients receiving continuous infusion experienced significantly shorter cumulative durations of MAP below 65 mmHg compared to those receiving manual boluses, suggesting better control and reduced exposure to hypotensive episodes.
6. Safety and Hypertension Risk: Although continuous norepinephrine infusion involved higher cumulative drug doses, it did not significantly increase the risk of hypertension, demonstrating its safety profile and manageable hemodynamic effects when carefully titrated.
7. Patient Selection and Risk Profile: The study specifically targeted older patients with chronic conditions such as hypertension, who are at greater risk for perioperative instability, highlighting the clinical relevance of these findings in real-world high-risk patient populations.
8. Practical Clinical Implications: The trial results advocate the routine use of continuous norepinephrine infusions to maintain stable blood pressure during induction of anesthesia in high-risk patients, potentially improving perioperative outcomes by minimizing hemodynamic instability.
9. Limitations and Future Research Needs: While promising, this study was limited by its small sample size, single-center design, short observational period, and lack of long-term clinical outcome assessments, indicating the necessity for larger multi-center trials.
10. Recommendations for Clinical Practice: The authors recommend considering continuous norepinephrine administration as a viable strategy for enhancing arterial blood pressure stability during anesthetic induction in patients undergoing high-risk noncardiac surgeries.

Conclusion

Continuous administration of norepinephrine during anesthetic induction significantly improves arterial blood pressure stability compared to intermittent bolus dosing in high-risk noncardiac surgery patients. This strategy offers a practical approach to enhance perioperative hemodynamic control, potentially reducing complications associated with post-induction hypotension.

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Discussion Questions

1. How can anesthesia teams best implement protocols for continuous norepinephrine infusion during induction to ensure consistency and safety in routine clinical practice?
2. What further research or evidence is required to confirm whether improved arterial blood pressure stability with continuous norepinephrine infusion translates into better long-term patient outcomes?
3. Given the differences in resource availability and clinical practices across hospitals, what are the barriers to adopting continuous norepinephrine infusion strategies widely, and how can these be addressed?

Javier Amador-Castañeda, BHS, RRT, FCCM, PNAP

Interprofessional Critical Care Network (ICCN)

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