NOREPINEPHRINE VERSUS EPINEPHRINE AS INITIAL VASOPRESSOR THERAPY IN ADULT SEPTIC SHOCK

Abstract

Importance: Septic shock remains a major cause of mortality among critically ill adults admitted to intensive care units. Vasopressor therapy is required when hypotension persists despite fluid resuscitation. Although norepinephrine is recommended as the preferred first-line vasopressor in adult septic shock, epinephrine continues to be used in selected patients because of its combined vasopressor and inotropic activity.

Objective: To evaluate the association between initial vasopressor choice, norepinephrine versus epinephrine, and clinical outcomes among adult patients with septic shock in a multicenter ICU cohort from tertiary-care hospitals of Lahore.

Design, Setting, and Participants: Retrospective multicenter ICU cohort of 350 adults admitted with septic shock. Patients were classified according to the first vasopressor infusion received after septic shock recognition.

Exposure: Initial norepinephrine infusion versus initial epinephrine infusion.

Main Outcomes and Measures: The primary outcome was 30-day all-cause mortality. Secondary outcomes included major adverse kidney events by day 30 (MAKE30), new kidney replacement therapy, persistent kidney dysfunction, intubation after vasopressor initiation, mechanical ventilation-free days, ICU-free days, hospital-free days, hydrocortisone use, additional vasopressor requirement, and tachyarrhythmia requiring treatment.

Results: Among 350 adult ICU patients, 230 received norepinephrine and 120 received epinephrine as the initial vasopressor. Unadjusted 30-day mortality was 22.6% in the norepinephrine group and 32.5% in the epinephrine group. MAKE30 occurred in 33.9% of patients receiving norepinephrine and 43.3% receiving epinephrine. After inverse probability of treatment weighting, epinephrine remained associated with higher estimated 30-day mortality, greater need for additional vasopressor support, and fewer ICU-free and hospital-free days.

Conclusions and Relevance: In this adult ICU cohort, norepinephrine as the initial vasopressor was associated with more favorable clinical outcomes than epinephrine in adult septic shock. Prospective and ethically approved local studies are needed to confirm whether these findings apply to routine ICU practice in Lahore.