Terlipressin versus norepinephrine to counteract intraoperative paracentesis induced refractory hypotension in cirrhotic patients

Back ground
Some of tense ascitic patients with end stage liver disease and portal hypertension were presented to our emergency department with surgical acute abdomen that required urgent abdominal surgery which might be associated with inevitable rapid and relatively complete evacuation of this ascitic fluid with possible occurrence of post-paracentesis-induced hypotension. The aims of this study were to compare between the intraoperative use of terlipressin versus norepinephrine for the management of paracentesis induced refractory hypotension not responding to colloid resuscitation or ephedrine in patients with end-stage liver disease during emergency abdominal surgery.
Patients and method
Thirty-four patients experienced refractory hypotension during or shortly after the paracentesis process were randomized to receive either bolus dose of terlipressin (1 mg over 30 min) followed immediately by a continuous infusion of 2 μg/kg/h (T group,  = 17) or norepinephrine infusion at starting dose of 0.1 μg/kg/min (N group,  = 17).
Measurements
Hemodynamic parameters, cardiac output, systemic vascular resistance, blood gases, lactic acid, liver and kidney functions.
Results
All patients of both groups showed significant decreases in MAP during or immediately after the paracentesis process to reach mean values of 57 ± 1.4 and 58 ± 1.8 mmHg in terlipressin or norepinephrine groups respectively. This was associated with drop in the SVR that reached mean values of 445 ± 28 and 425 ± 20 dynes/sec/cm in both terlipressin and norepinephrine groups respectively. At the 2nd day post operative there was significant increase in serum creatinine values in the norepinephrine group.
Conclusion
Terlipressin and norepinephrine successfully counteracted the post-paracentesis refractory hypotension and the drop of the systemic vascular resistance. It also showed the renal protective effects of terlipressin in the immediate postoperative period.