Septic shock: early norepinephrine improves shock control in prospective CENSER

  • Permpikul C & al.
  • Am J Respir Crit Care Med
  • 1 Feb 2019

  • curated by Jenny Blair, MD
  • Clinical Essentials
Access to the full content of this site is available only to registered healthcare professionals. Access to the full content of this site is available only to registered healthcare professionals.


  • For patients with septic shock, early norepinephrine during resuscitation resulted in better short-term shock control but no improvement in mortality as a secondary outcome.
  • Larger trials are needed.

Why this matters

  • Despite promising retrospective studies, few prospective data were previously available to support this intervention. 
  • Patients randomly assigned earlier than in 3 previous studies of early goal-directed therapy (ProCESS, ARISE, and ProMISe), according to authors.

Key results

  • Median time from emergency department arrival to norepinephrine: 93 minutes.
  • Norepinephrine vs standard treatment (95% CIs):
    • Shock control: 76.1% vs 48.4%; OR, 3.4 (2.09-5.53); P<.001.>
    • 28-day mortality: 15.5% vs 21.9%; relative risk, 0.79 (0.53-1.11); P=.15.
    • No differences in respiratory failure requiring ventilator support, renal failure requiring renal replacement therapy, organ support-free days, or limb or intestinal ischemia.
  • With norepinephrine, less cardiogenic pulmonary edema, new-onset arrhythmia.

Study design

  • Single-center randomized controlled double-masked CENSER trial (n=310). 
  • Adults with sepsis and hypotension randomly assigned to early norepinephrine vs standard treatment (2012 Surviving Sepsis guidelines). 
  • Outcome: shock control at 6 hours.
  • Funding: Siriraj Critical Care Research Funding (Bangkok, Thailand).


  • Single-center trial.
  • Fluid rates were not controlled.
  • Primary outcome was not patient-centered.
  • Many patients had to be managed on the ward, not the ICU.

Please confirm your acceptance

To gain full access to GPnotebook please confirm:

By submitting here you confirm that you have accepted Terms of Use and Privacy Policy of GPnotebook.