Vasopressor Selection in Refractory Anaphylaxis

adrenaline in anaphylaxis vasopressor May 04, 2026

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.

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References:

 Kolawole, H., Marshall, S.D., Crilly, H., Kerridge, R., Roessler, P. (2023). Vasopressor selection in refractory anaphylaxis. Anaesthesia and Intensive Care.

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