Sevrage de la noradrénaline dans le choc septique

Norepinephrine has become a standard of care in the hemodynamic management of septic shock recommended in several international guidelines concomitantly to volume expansion. However, no guidelines exist concerning norepinephrine weaning that ensues. Furthermore, the pharmacodynamic effects that constitute the basis for norepinephrine use in septic shock, i.e., venous and arterial vasoconstriction, may rapidly restore macrocirculatory hemodynamics, albeit at the cost of latent regional or microcirculatory perfusion disorders, all the more so in the absence of optimal volume expansion. Norepinephrine weaning, which decreases stressed volume, may therefore crucially reveal any latent or persisting volume deficit. Despite this importance, norepinephrine weaning has received little attention, and has been shown to be arbitrarily performed, needlessly prolonging potentially harmful effects. Norepinephrine weaning could be viewed as hemodynamic functional tests during which preload dependency could be assessed and either reveal latent/residual need for volume expansion allowing weaning to be pursued in a shorter timeframe or reveal norepinephrine-dependence interrupting the process. Such norepineprhine weaning tests may even have an important role during the initial hemodynamic management of septic shock in order to prevent regional or microcirculatory perfusion disorders in apparently resuscitated septic shock. Thus, norepinephrine weaning in septic shock is an important issue that deserves more attention.