Most perioperative anaphylaxis responds to adrenaline. But occasionally, despite timely and appropriate dosing, the patient remains profoundly hypotensive. This is where things start to feel uncertain.
Refractory anaphylaxis is not just “more of the same.” It reflects a complex mix of severe vasodilation, capillary leak, and sometimes impaired response to catecholamines. Under anaesthesia, these effects can be amplified, and the usual first-line treatment may not be enough.
Adrenaline remains the cornerstone, but when response is inadequate, additional vasopressors may be needed to restore vascular tone and support perfusion.
- ⚡ Noradrenaline supports systemic vascular resistance and can be helpful when vasodilation dominates
• ⚡ Vasopressin works independently of adrenergic receptors and may be useful in catecholamine-resistant shock
• ⚡ Metaraminol can provide temporary support but is not a definitive strategy in severe cases
• ⚡ Glucagon may be considered in patients on beta-blockers where adrenaline response is blunted
• ⚡ Ongoing fluid resuscitation is essential alongside any vasopressor therapy
The choice is not about replacing adrenaline, but about supporting it.
In practice, this often means early escalation. If hypotension persists despite repeated adrenaline and fluid boluses, introducing a second agent can help stabilise the patient while the underlying reaction is treated.
For perianaesthesia nurses, this is where anticipation matters. Recognising refractory patterns early allows the team to prepare infusions, escalate promptly, and avoid further deterioration.
When adrenaline alone is not enough, thoughtful vasopressor selection can bridge the gap between instability and recovery.
Build Knowledge ✅
Improve Safety ✅
References:
Kolawole, H., Marshall, S.D., Crilly, H., Kerridge, R., Roessler, P. (2023). Vasopressor selection in refractory anaphylaxis. Anaesthesia and Intensive Care.
Stay connected with news and updates!
Join our mailing list to receive the latest news and updates from our team.
Don't worry, your information will not be shared.
We hate SPAM. We will never sell your information, for any reason.
Unlock Exclusive Free Content
Join the mailing list. We give too much great content away for free, see what all the fuss is about.
Categories
All Categories abg acid base acidosis acorn adrenaline adrenaline dosing adrenaline in anaphylaxis advanced advancedhaemostats adverse reaction aed agents ahpra ahpra audit airway airway adjuncts airway assessment airway emergency airway filter airway management airway mass airway rescue airway trauma airwaylifeline airwayoptimisation algorithm allergy als als aftercare alsmedications amiodarone anaesthesia anaesthetic anaesthetic machine anaesthetics analgesia anaphylactoid anaphylaxis anaphylaxis aftercare anaphylaxis diagnosis anaphylaxis differential diagnosis anaphylaxis management anaphylaxis triggers anatomy antibiotics antiemetic anzaag anzcor apnoea arrest arterial blood gas arterial line arterial line complications arterial line errors arterial lines arterialcannulation arteriallines asa article asl aspiration aspiration risk assessing pain assessment awareness bag mask ventilation behaviours of concern beta blockers bis bispectral index blade bleed bleeding bleeding airway block blocks blood blood glucose blood pressure blood pressure monitoring blood products blood safety bluey boundaries breathing circuit bronchoscopy bronchospasm burns calcium cannula technique cannulation capnography cardiac arrest cardiac collapse cardiac output cardiac surgery cardiovascular causesofcardiacarrest cell saver central venous catheter centralvenouscatheter cerebral oximetry checklist checklists chlorhexidine cico circadian cycle circuit classification climate climate change clinicaldecisionmaking clinicalpractice closed loop communication co2 coagulation coagulopathy cognitive aid colonoscopy communication complications compression rates compressions contaminant coolinginmh core body temperature cpd cpr cricoid pressure cricothyrotomy crisis crisis resource management critical incident criticalbleeding cross matching cvc cvc complications dantrolene debriefing decisions defibrillation dental surgery depth of anaesthesia diabetes diagnostics difficult airway documentation drug errors drug safety drugs ecg education educator emergence delirium emergency emergency management emotional intelligence end tidal carbon dioxide endoscopy endotracheal tubes ent entropy environment epidural anaesthesia equipment ercp error ett exchange catheter exercise fasting feedback ffp fluid balance fluid resuscitation fluid therapy fona formal diagnosis fracture fixation principles fracture patterns frailty ga gas gas analysis gastroscopy general anaesthetic gloves glp-1 ra glp-1 receptor agonists glp-1ras haemodynamic haemoglobin haemorrhage haemostasis haemostatic haemostaticagents haemostats handle handover hazard health heart rate hemodynamics hereditarydisorder high flow high risk hot debrief human factors hypnosis hypoglycaemia hypotension hypothermia hypoxia icu immune response incomplete reversal induction infection infection control inotrope inotropes intravenous intravenous cannulation intubation invasive blood pressure monitoring invasive device invasivebloodpressuremonitoring iv induction ketamine laryngeal mask laryngectomy laryngoscope laryngospasm last leadership learning lifelines lma local anaesthetic long term venous access major surgery malignanthyperthermia mallampati mask ventilation massive transfusion massive transfusion protocol mast cells mean arterial pressure medications mh mhtesting mls monitoring movement muscle relaxants neck surgery nerve blocks nerve monitoring neuraxial neuromuscular blockade neuromuscular junction nmt non-invasive blood pressure non-shockable rhythms nurse burnout nurse education nurse wellbeing nurselife nursing nursingeducation nutrition obstetric obstetrics anaesthesia obstruction operatingroom opioid opioids orthopaedic biology orthopaedic nursing ot oxygen oxygenation ozempic pacu paediatric paediatric anaesthesia paediatric t piece paediatrics pain pain management passive patient safety patientbloodmanagement perianaesthesia nurse educator perioperative perioperative orthopaedics perioperativenurse perioperativenursing physiology pipeline platelets ponv positioning post op bleed post operative preoperative preoperative care preoxygenation preparedness primary survey professional development protocol psychological safety publications pulmonary radiation rapid sequence induction recognition recovery recovery issues recovery room emeregencies refractory anaphyalxis refractory hypotension regionalanaesthesia renal resilience resources respiratory resuscitation reversal rotem safe apnoea time safety scalpel scalpel technique scoutnurse scrub scout nursing scrubnurse sedation seldinger shared airway shock shockable rhythms signs of anaphylaxis simulation skin prick testing sleep spinal spinal anaesthetic sterile procedures stress reduction surgery surgical surgical considerations surgical safety checklist surgicalcare surgicalphysiology surgicalpractice surgicalsafety surgicaltechniques systemic tachycardia teaching styles team time-out teamwork techniques teg temperature testing therapies tonsillectomy topical topicalhaemostats tracheostomy training tranexamic acid transfusion transfusion reaction trauma treatment tryptase ultrasound ultrasoundprobes vascular surgery vasopressor ventilation vf videolaryngoscope volatileagents vortex approach vt waste wellbeing whole blood workshop