In this episode, I’ll discuss a scenario where phenylephrine may be a preferred vasopressor.
Because of poor effects in patients with septic shock, phenylephrine is often thought of as a poor first-line vasopressor choice. However, not all causes of hypotension are equal and there may be circumstances where phenylephrine is preferred. A recent retrospective cohort study published in Anesthesia and Analgesia suggests that severe traumatic brain injury might be one of those circumstances.
The primary exposure examined was the vasopressor choice (phenylephrine versus norepinephrine) within the first 2 days of hospital admission and the primary outcome was in-hospital mortality.
The study spanned a 10 year period and over 66,000 patients were included in the analysis. After excluding patients who received a vasopressor other than phenylephrine or norepinephrine and those who received more than 1 vasopressor, 14,991 patients received only phenylephrine and 2668 patients received only norepinephrine.
The authors performed a propensity-matched analysis and found that norepinephrine was associated with an increased risk of in-hospital mortality when compared to phenylephrine with an odds ratio of 1.65.
The authors called for randomized trials to better inform vasopressor choice for severe TBI patients. Until such trials can be conducted this study suggests phenylephrine should be used first before norepinephrine if the cause of hypotension is severe TBI.
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