Sudden loss of blood pressure in a patient on a stable noradrenaline infusion is far more often a delivery problem than a change in the patient. A bag that has run dry, an occluded or kinked line, a disconnected extension, a pump on hold after an alarm, extravasation into the tissue, or a flush that has just delivered a bolus and left nothing behind it — all of these look exactly like refractory shock for the first minute.
The reflex to escalate is the wrong one to follow first because it is slower and it misleads. Turning the rate up on a line that is not delivering produces no response, which is then read as deterioration, which produces further escalation, and the eventual correction delivers everything that has accumulated at once.
The habit is to trace the line from the pump to the cannula with your hand before touching the rate. It takes a few seconds and it is the commonest reversible cause of what looks like sudden decompensation on a critical care unit.
- Trace the infusion from pump to cannula by hand before changing the rate
- Check the bag volume and the pump status, including whether it is silently on hold
- Look at and feel the cannula site for extravasation, particularly in a peripheral vasopressor infusion
- Ask what was flushed or given down that line in the last minute
- Escalate the dose only once you have confirmed the drug is reaching the patient
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