Question

Does the use of norepinephrine for hypotension in immediate post-CABG patients have adverse effects on the grafts (arterial or venous, either)?

Norepinephrine and graft function for post-CABG hypotension. Adverse effect in terms of vasoconstriction, that may compromise graft function.

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  • François Brivet · Université Paris-Sud 11
    Norepinephrine (NE) is useful in case of hypotension when preload is optimized. Early aggressive resuscitation of critically ill patients limit or, even more reverse, tissue hypoxia, and thus progression to organ failure. NE in these conditions improves the outcome.
    NE use in case of uncorrected hypovolemia induces an inappropriate perfusion of vasopressors which may increase organ hypoperfusion, ischemia and the risk of death. Remember that a the end of the nineteenth century, 100 percent of patients with gastrointestinal bleeding treated with adrenaline, without fluid resuscitation die of ischemic necrosis of the stomach (published in the Lancet).
    Therefore, NE is useful and must be used in case of vasoplegia and corrected preload. Too little fluid induces hypoperfusion, worsen graft function, too much fluid decreases oxygen delivery.
    NE is always useful in case of vasoplegia (sepsis, allergy… and other diseases) after a “correct fluid resuscitation”. Furthermore , its use is now recommended in the early phase of shock, if diastolic pressure is less than 45 mmHg IN ASSOCIATION with rapid fluid administration
  • Vladimir Cernak · University of Groningen
    Very nice question. Always discussion point with the surgeon. In this matter is very interesting the study of Park 2011 " Comparative effects of norepinephrine and vasopressin on internal thoracic arterial graft flow after off-pump coronary artery
    bypass grafting". They found that NE increases the flow in internal thoracic artery. I can imagine that graft with. a. radialis could be more sensitive to the effect of NE.
  • Sonali Vadi · Global Hospitals Group
    Thank you Vladimir Cernak
  • Venugopal Rao · Sri Jayadeva Institute of Cardiovascular Sciences & Research
    NE in the setting of low cardiac output with severe reduction in SVR Is a good option.But if SVR is already high, NE may reduce the flow across grafts ,especially the arterial and more so in Radial grats.

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