Effectiveness of prophylactic push-dose vasopressors for preventing arterial hypotension during elective orotracheal intubation: A systematic review and meta-analysis.

BACKGROUND

Orotracheal intubation is frequently associated with arterial hypotension, particularly during induction with agents such as propofol. The use of prophylactic push-dose vasopressors (Push-Dose Pressor - PDP) has been proposed to mitigate this drop in blood pressure. However, the effectiveness of PDPs remains uncertain.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing the use of PDPs (epinephrine, ephedrine, phenylephrine, or metaraminol) during sedation for tracheal intubation in adult normotensive patients. Searches were performed in MEDLINE, Embase, and Cochrane Library from inception to September 2024. The primary outcome was the difference in mean arterial pressure (MAP) and systolic blood pressure (SBP) before and after intubation between patients who received PDPs and those who did not. Data were synthesized using an inverse variance method, with heterogeneity assessed using Cochran's Q and I2.

RESULTS

Twenty-four RCTs involving 1915 patients were included. Most trials were conducted in operating rooms among ASA I-II patients undergoing elective procedures. PDP administration resulted in higher MAP (mean difference: 7.6 mmHg; 95 % CI: 4.3-10.8; I2 = 82 %) and SBP (mean difference: 12.5 mmHg; 95 % CI: 6.4-18.5; I2 = 92 %) compared with controls. Sensitivity analyses excluding phenylephrine or stratifying ephedrine doses yielded consistent findings. Overall certainty of evidence was low due to heterogeneity and indirectness.

CONCLUSIONS

Prophylactic push-dose vasopressors modestly increase arterial pressure during tracheal intubation in elective surgical patients. Given the low certainty of evidence and limited generalizability, routine use cannot be currently recommended.