Septic shock: norepinephrine increased urine output in most patients.

Clinical bottom line (level 4)

  1. Norepinephrine infusion increased urine output and creatinine clearance and decreased creatinine levels in around 80% of patients with septic shock.
  2. Response was similar in patients receiving and not receiving dopamine and dobutamine.
  3. Its effects on long-term outcomes were not addressed.
Martin et al: Critical Care Medicine 1990; 18 (3): 282-285
Expires July 2003

The study

Retrospective cohort study with objective outcomes, not adjusted for confounding factors, not validated in an independent set of patients.
Setting: intensive care unit of an acute hospital, France

24 patients (aged mean 55 years, 79% male) oliguric with septic shock, diagnosed if:
  • systolic blood pressure 90 mmHg or less
  • urine output <30 ml/hour
  • bacteraemia or an identified source of infection

Control Group: (n = 24, 24 analysed): before therapy
Experimental Group: (n = 24, 24 analysed): after therapy with norepinephrine (0.5 µ g/kg/min with increments of 0.3 to 0.6 µ g/kg/min) if cardiac index > or = 4 l/min/m ² and systemic vascular resistance index <350 dyne sec/cm 5 /m ² until systolic blood pressure was within normal range, with or without dobutamine (starting at 6 µ g/kg/min with increments of 3 µ g/kg/min) if cardiac index <3.5 l/min/m ² , or dopamine (used in patients who were already receiving it before entry to ICU)
All patients received mechanical ventilation due to concomitant acute respiratory failure, iv. broad spectrum antibiotics, and fluid resuscitation (1450 ± 127 ml) to optimise left ventricular preload. No patient had steroids.
100% followed for 2 days

The evidence

Outcome Control Group
(SD)		 Experimental Group
(SD)		 Mean Difference
(95% CI)
urine flow (ml/hour) 16
(13) 		93
(59) 		77
(52 to 102)
creatinine ( µ mol/l) 186
(160) 		110
(50) 		-76
(-7.12 to -145)
creatinine clearance (ml/min/1.73 m ² ) 39
(28) 		70
(35) 		31
(13 to 49)

  • Baseline creatinine clearance estimated in 2/3 of patients

    • Comments

    1. The change in creatinine and creatinine clearance over the 48 hours reflects many factors other than the norepinephrine and is difficult to interpret in view of the lack of a control group.
    2. It is may be the benefits of norepinephrine were related to the increase in blood pressure rather than a specific effect on renal perfusion.

    Citation

    1. Martin C, Eon B, Saux P, et al: Renal effects of norepinephrine used to treat septic shock patients. Critical Care Medicine 1990; 18 (3): 282-285
    Search Terms: reference list
    Contributor: Catherine Clase, Chris Ball and Clare Wotton, April 2000
    Reviewer: Janice L Zimmerman

    Clinical Question.
    Patient oliguria and septic shock
    Intervention or Exposure norepinephrine
    Outcome urine output