Norepinephrine Infusion in the Emergency Department in Septic Shock Patients: A Retrospective 2-Years Safety Report and Outcome Analysis

Antonio Messina, Angelo Milani, Emanuela Morenghi, Elena Costantini, Stefania Brusa, Katerina Negri, Daniele Alberio, Ornella Leoncini, Silvia Paiardi, Antonio Voza, Maurizio Cecconi
International Journal of Environmental Research and Public Health 2021 January 19, 18 (2)

Hemodynamic optimization during sepsis and septic shock is based on a prompt and large fluid resuscitation strategy associated with early administration of norepinephrine. In our hospital, norepinephrine is administered in the emergency department (ED), within a protocol-guided management context, to reduce norepinephrine infusion timing due to central line insertion. This choice, however, can be associated with side effects.

OBJECTIVES: We conducted a retrospective analysis regarding the safety of norepinephrine in the ED. We also appraised the association between in-hospital mortality and predefined ED variables and patients' admission severity scores.

DESIGN, SETTINGS, AND PARTICIPANTS: This was a retrospective analysis of electronic sheets of the ED of a tertiary hospital in the North of Italy. Outcomes measure and analysis: Electronic documentation was assessed to identify local and systemic side effects. We considered two subgroups of patients according to the in-hospital clinical paths: (1) those admitted in the intensive care unit (ICU); and (2) those who received a ceiling of care decision. We collected and considered variables related to septic shock treatment in the ED and analyzed their association with in-hospital mortality.

MAIN RESULTS: We considered a two-year period, including 108,033 ED accesses, and ultimately analyzed data from 127 patients. Side effects related to the use of this drug were reported in five (3.9%) patients. Thirty patients (23.6%) were transferred to the ICU from the ED, of whom six (20.0%) died. Twenty-eight patients (22.0%) received a ceiling of care indication, of whom 21 (75.0%) died. Of the 69 (54.3%) finally discharged to either medical or surgical wards, 21 (30.4%) died. ICU admission was the only variable significantly associated to in-hospital mortality in the multivariable analysis [OR (95% CI) = 4.48 (1.52-13.22); p -value = 0.007].

CONCLUSIONS: Norepinephrine peripheral infusion in the ED was associated with a low incidence of adverse events requiring discontinuation (3.9%). It could be considered safe within <12 h when a specific line management protocol and pump infusion protocol are adopted. None of the variables related to septic shock management affected in-hospital mortality, except for the patient's ICU admission.

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