BET 3: Peripheral metaraminol infusion in the emergency department

Three-part question In (adult patients presenting to the ED with sepsis resulting in persistent hypotension not responding to fluid replacement) is a (peripheral metaraminol infusion as effective as central catecholamine infusion) for (maintaining a blood pressure capable of effective organ perfusion)?

Clinical scenario A previously fit and well 36-year-old male returns from a holiday to Greece 48 hours ago and presents to the ED complaining of headache, malaise and feeling generally unwell. While waiting to be seen, the patient’s headache rapidly worsens, he spikes a high temperature of 38.9°C, becomes increasingly agitated and starts vomiting. He is taken to a resuscitation cubicle and has a HR of 135 bpm and BP of 71/45 mm Hg. Examination of the patient reveals several small non-blanching petechiae. You manage the patient as suspected meningitis and commence appropriate sepsis management. After administrating 3 L of intravenous fluid, the patient remains with a systolic BP <80 mm Hg. The intensive care doctor informs you that they are trying to make a space available in the intensive treatment unit for this patient but are struggling to step anyone down and the patient must remain in the resuscitation department. The resuscitation nurse asks you to prescribe more fluid. You wonder whether a peripheral metaraminol infusion would be more effective at increasing arterial pressure and maintaining organ perfusion.