Early norepinephrine resuscitation of life-threatening hypotensive septic shock: it can do the job, but at what cost?

ects of early norepinephrine for septic shock with lifethreatening hypotension. Th eir observations fi rst answer ‘yes’ to the question ‘Can norepinephrine alone restore mean arterial pressure (MAP) in septic shock?’ Second, as an answer to ‘How does norepinephrine alone restore MAP?’, they confi rm that norepinephrine restores MAP despite minimal fl uid administration through ‘recruiting’ unstressed volume while allowing increased contractility despite increasing afterload. Th e most critical question that remains unanswered, however, is ‘Should nor epinephrine alone be used to restore MAP in septic shock?’ If the price of fl uid resuscitation may be edema and organ failure, what may be the price of norepinephrine resuscitation? Th e fear is that the very same eff ects that allow norepinephrine to recruit unstressed volume, through alpha adrenergic eff ects on venous and arterial vasculature, might recruit volume to the macrovas culature, all the while decreasing fl ow in previously critically collapsible microvascular beds. Answers to this crucial question are still unclear. In two previous confl icting studies showing benefi cial [2] or detrimental [3] eff ects on microvascular blood fl ow, the discrepancies may have been due to diff erences in prior fl uid therapy and ensuing preload reserve. In order to determine the optimal use of norepinephrine, future studies of microcirculation and perfusion should either optimize on an indicator of fl uid responsiveness during the fl uid therapy preceding norepinephrine treatment or rapidly wean the inevitable early norepinephrine infusion rate once the targeted MAP is obtained by screening for and addressing preload dependency during infusion rate decrements [4].