Category: Critical Care
Keywords: Intubation, RSI, norepinephrine, hypotension, vasopressors (PubMed Search)
Posted: 12/29/2025 by Mark Sutherland, MD
(Updated: 12/30/2025)
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Perintubation hypotension is a major problem, and can precipitate hemodynamic collapse and cardiac arrest for a multitude of reasons. To prevent this, many different strategies have been explored (some of which work and some of which don't), including empiric IV fluid boluses, additional resuscitation before intubation, switching or dose-reducing induction agents and much more. But we know pressors like norepinephrine raise blood pressure effectively, so should we just put everybody on a norepinephrine drip before we intubate them?
Probably not. The EPITUBE trial included 210 patients at a single-institution undergoing cardiac surgery, and randomized them to empirically starting a norepinephrine infusion before induction vs just rescue ephedrine when needed (fairly standard anesthesia practice). For the empiric norepinephrine group, they started at 0.06 ug/kg/min, and once the drip was up and running, they titrated for a MAP of 65-80 (which could include stopping the norepi if that the patient remained above 80 despite downtitration)
The incidence of severe hypotension (MAP < 55) did not differ between the groups, although fewer empiric norepinephrine patients had a MAP < 65 at any point (which was a secondary outcome). Naturally, the differences between this practice setting (the cardiac surgery OR) and the emergency department should be noted and are not addressed by this study.
Bottom line: There isn't good evidence to support empirically starting all patients on a norepinephrine infusion prior to intubation as a method to prevent perintubation hypotension. You should always have rapid access to vasopressors when intubating, and should continue to tailor your therapy to the individual patient, but probably don't start just putting everyone on norepinephrine before you intubate them.
