When managing a patient with shock in the emergency department (ED), when should intravenous (IV) fluids be administered and for how long, and at what point should noradrenaline be initiated?

From the Guidelines

In managing a patient with shock in the emergency department, IV fluids should be administered immediately upon recognition of shock, starting with a 30 mL/kg crystalloid bolus over the first 1-3 hours, as recommended by the Surviving Sepsis Campaign guidelines 1. This initial fluid resuscitation should be followed by reassessment of hemodynamic parameters including blood pressure, heart rate, capillary refill, urine output, and mental status. Additional fluid boluses of 500-1000 mL may be given based on ongoing assessment. The goal is to restore a mean arterial pressure of 65 to 70 mmHg, which is a good initial goal during hemodynamic support of patients with sepsis 1. Noradrenaline (norepinephrine) should be initiated if the patient remains hypotensive (typically systolic BP <90 mmHg or MAP <65 mmHg) after 2-3 liters of fluid or shows signs of fluid overload. The starting dose is typically 0.05-0.1 mcg/kg/min, titrated every 5 minutes to maintain a mean arterial pressure of 65-70 mmHg, with a maximum dose of 3.3 mcg/kg/min 1. Early vasopressor initiation (within 1-2 hours) is particularly important in septic shock where excessive fluid administration can be harmful. Central venous access is preferred for noradrenaline administration, though peripheral administration through a large vein can be used temporarily while central access is being established. Some key points to consider in the management of shock include:

• Early identification of sepsis and prompt administration of intravenous fluids and vasopressors are always mandatory 1
• Restoring a mean systemic arterial pressure of 65 to 70 mm Hg is a good initial goal during the hemodynamic support of patients with sepsis 1
• Norepinephrine is now the first-line vasopressor agent which is used to correct hypotension in the event of septic shock 1
• Septic shock is defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities who are associated with higher risk of mortality than with sepsis alone 1

From the FDA Drug Label

Correct Hypovolemia Address hypovolemia before initiation of Norepinephrine Bitartrate Injection therapy. If the patient does not respond to therapy, suspect occult hypovolemia After an initial dosage of 8 to 12 mcg per minute via intravenous infusion, assess patient response and adjust dosage to maintain desired hemodynamic effect.

The patient should be given IV fluids to address hypovolemia before initiating noradrenaline therapy.

• The duration of IV fluid administration is not explicitly stated, but it should be continued until hypovolemia is corrected.
• Noradrenaline should be initiated promptly if the patient does not respond to IV fluid therapy, suggesting occult hypovolemia.
• The initial dosage of noradrenaline is 8 to 12 mcg per minute via intravenous infusion, and the dosage should be adjusted to maintain the desired hemodynamic effect 2.
• Blood pressure should be monitored every two minutes until the desired hemodynamic effect is achieved, and then every five minutes for the duration of the infusion.

From the Research

Management of Shock in the Emergency Department

• The management of shock in the emergency department (ED) involves the administration of intravenous (IV) fluids and vasopressors, such as noradrenaline, to restore circulatory function and improve tissue perfusion 3, 4.
• The approach to fluid therapy should be individualized based on the cause of shock, as well as the patient's major diagnosis, comorbidities, and hemodynamic and respiratory status 3.

Administration of IV Fluids

• IV fluids should be administered to patients with hypovolemic shock, as well as to those with other types of shock who are hypovolemic or have a low cardiac output 5, 6.
• The goal of fluid resuscitation is to restore circulating volume and optimize cardiac output, but excessive fluid administration can be harmful and increase morbidity and mortality 3, 5.
• The duration of IV fluid administration should be guided by the patient's response to therapy, including improvements in blood pressure, urine output, and other indicators of tissue perfusion 3, 6.

Initiation of Noradrenaline

• Noradrenaline should be initiated promptly in patients with vasodilatory shock who are not responsive to volume resuscitation, as well as in those with cardiogenic shock or hypovolemic shock who require additional support 4, 7.
• The dose of noradrenaline should be titrated to achieve a mean arterial pressure (MAP) of at least 65 mmHg, while minimizing the risk of adverse effects such as excessive vasoconstriction and organ ischemia 7.
• Examples of patients who may require noradrenaline include those with septic shock who are not responding to fluid resuscitation, as well as those with cardiogenic shock who have a low cardiac output despite adequate fluid administration 4, 7.

Examples of Patient Management

• A patient with hypovolemic shock due to bleeding should receive IV fluids to restore circulating volume, with the goal of achieving a MAP of at least 65 mmHg 3, 6.
• A patient with septic shock who is not responding to fluid resuscitation should be started on noradrenaline to support blood pressure and improve tissue perfusion 4, 7.
• A patient with cardiogenic shock due to myocardial infarction should receive IV fluids to optimize cardiac output, as well as noradrenaline if necessary to support blood pressure and improve tissue perfusion 4, 7.