Continuous Norepinephrine Infusion: A Shift in Perioperative Hemodynamics

A randomized trial in a high‑risk noncardiac surgical cohort found that continuous norepinephrine infusion during anesthesia induction provided superior hemodynamic control versus manual bolus dosing—reducing early postinduction mean arterial pressure (MAP) variability and lowering the immediate periinduction hypotension burden.

The report describes randomization of 71 patients (36 infusion, 35 bolus) with continuous invasive arterial monitoring used in the protocol, and it emphasizes improved MAP stability in the minutes after induction as the primary hemodynamic advantage of infusion-based titration.

Tighter MAP control limits exposure to harmful hypotension and is plausibly linked—both physiologically and in observational analyses—to reduced perioperative end‑organ injury, including acute kidney injury.

Practical steps to reproduce the trial’s induction benefit include preparing an infusion pump and a preloaded norepinephrine syringe before induction, selecting a low starting infusion rate with rapid titration toward a prespecified MAP target, increasing monitoring intensity (or using invasive arterial pressure monitoring) for high‑risk patients, and confirming secure IV access with an immediate rescue bolus plan available.

Key Takeaways:

• Continuous norepinephrine infusion during induction reduced MAP variability and early hypotensive episodes compared with bolus dosing in the reported cohort.
• Improved MAP control during induction is a plausible mechanism to reduce perioperative organ‑injury risk in high‑risk patients, but attribution of long‑term clinical benefit requires confirmatory outcome data.
• Teams seeking to operationalize this approach should standardize infusion preparation, define MAP targets, and escalate monitoring for higher‑risk cases.
• Wider adoption should be coupled with implementation research and guideline review before treating this as a standard of care.