Key result
Norepinephrine cuts intraoperative hypotension duration vs. other vasopressors while preserving cardiac index.
Why the study?
Intraoperative hypotension during noncardiac surgery is linked to AKI, MINS, and 30-day mortality. While management historically relied on reactive boluses of ephedrine or phenylephrine, growing evidence suggests advantages with norepinephrine, prompting a synthesis of contemporary diagnostic definitions and comparative vasopressor efficacy and safety.
Does intraoperative norepinephrine (via continuous micro-infusion or early bolus titration) reduce the duration and incidence of intraoperative hypotension while preserving systemic hemodynamics compared to traditional vasopressor strategies (phenylephrine or ephedrine) in adults undergoing non-cardiac surgery under general anesthesia?
Systematic Review (n=12,415)
Yes
Does intraoperative norepinephrine (via continuous micro-infusion or early bolus titration) reduce the duration and incidence of intraoperative hypotension while preserving systemic hemodynamics compared to traditional vasopressor strategies (phenylephrine or ephedrine) in adults undergoing non-cardiac surgery under general anesthesia?
This systematic review demonstrates that early or continuous norepinephrine infusion reduces intraoperative hypotension duration while preserving cardiac output compared to phenylephrine or ephedrine in non-cardiac surgery, and is safe for peripheral intravenous administration.
Answers are grounded in this paper and cite their sources.
Norepinephrine shortens hypotension duration while preserving cardiac index; challenges phenylephrine-first practice and extends evidence for mixed-agonist vasopressors.
Background & Objective: Intraoperative hypotension (IOH) is a frequent complication during non-cardiac surgery under general anesthesia, strongly linked to acute kidney injury (AKI), myocardial injury after noncardiac surgery (MINS), and increased 30-day mortality.Historically, intraoperative blood pressure management relied predominantly on reactive boluses of ephedrine or phenylephrine.However, growing contemporary evidence suggests physiological and clinical advantages with the early administration or continuous infusion of norepinephrine.This systematic review aimed to describe and synthesize contemporary trends in diagnostic definitions of IOH, identify first-line and rescue vasopressors, and evaluate their comparative clinical efficacy and safety profiles.A systematic review was Methods: conducted in adherence to the PRISMA 2020 guidelines and prospectively registered in PROSPERO (ID: 1129957).Comprehensive electronic database searches were conducted across PubMed/MEDLINE, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL) up to 2025.Eligible studies included randomized controlled trials (RCTs), prospective/retrospective cohorts, and case-control studies in adult patients (≥ 18 years) undergoing noncardiac surgery under general anesthesia evaluating vasopressors for IOH management.Risk of bias was critically appraised using the Cochrane RoB 2 tool for RCTs and the Newcastle-Ottawa Scale (NOS) for observational studies.Results: From 127 identified records, 8 studies fully met inclusion criteria (3 RCTs, 3 cohort studies, and 2 case-control studies; total N = 12,415 patients).Diagnostic criteria varied across cohorts, but a mean arterial pressure (MAP) < 65 mmHg or a relative decline ≥ 20-30% from pre-induction baseline predominated.Norepinephrine (administered via continuous micro-infusion or titrated early boluses) emerged as the preferred first-line vasopressor in contemporary protocols.Compared with pure 1-agonists (phenylephrine), norepinephrine significantly reduced the cumulative duration of hypotension (p < 0.01) while preserving stroke volume and cardiac index.Furthermore, peripheral intravenous infusion of diluted norepinephrine under standardized safety protocols showed no severe extravasation injuries or distal limb ischemia across large observational registries.Contemporary surgical practice Conclusions: demonstrates an international paradigm shift establishing norepinephrine as the optimal first-line vasopressor for managing IOH under general anesthesia, displacing traditional monotherapy with ephedrine or phenylephrine.Standardizing diagnostic thresholds to a strict threshold of MAP ≥ 65 mmHg and adopting protocolized vasopressor pathways are essential to mitigate end-organ hypoperfusion and postoperative morbidity.
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Jara et al. (2026) conducted a systematic review in Intraoperative hypotension in non-cardiac surgery under general anesthesia (n=12,415). Norepinephrine (via continuous micro-infusion or titrated early boluses) vs. Traditional vasopressor strategies (phenylephrine or ephedrine monotherapy), standard reactive care, or differential MAP target thresholds was evaluated on Cumulative duration of intraoperative hypotension (MAP < 65 mmHg) and maintenance of systemic hemodynamics (stroke volume, cardiac output) (p=< 0.01). Norepinephrine significantly reduced the cumulative duration of intraoperative hypotension (p < 0.01) while preserving stroke volume and cardiac index compared to phenylephrine or ephedrine.
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