Non-ICU Administration of Norepinephrine for HRS

Introduction: Addition of vasoconstrictor is the standard of care for treatment of patients with HRS-AKI. Terlipressin is the only FDA approved vasoconstrictor but it is not available in all hospitals. Norepinephrine is equally effective but it requires the patient to be transferred to the ICU for administration. However ICU beds are in high demand and here we present a case for norepinephrine use for HRS in a specialized liver floor outside of the ICU. Case Description: 67 yo Caucasian female was admitted with decompensated alcoholic cirrhosis with MELD score of 37, and ascites. Nephrology was consulted for creatinine of 1.98mg/dL elevated from baseline of <1 mg/dL. After 48 hours, the diagnosis of HRS-AKI was done using the ICA 2024 criteria. The patient creatinine went up to 2.1 mg/dL and patient was started on non-ICU specialized liver unit protocol for norepinephrine administration for HRS via central line with a goal to increase the MAP up to 15 mmHg from the baseline of 61 without exceeding the dose of 10mg/min. Therapy was continued for 7 days with the highest dose administered of 6 mcg/min and creatinine improved back to baseline. The patient did not develop any complication throughout the course of norepinephrine administration and was started on midodrine after completion of therapy. Discussion: Treatment of HRS-AKI with norepinephrine is a safe and cost effective choice for treatment of HRS-AKI without the need for the patient to be transferred to the intensive care unit using a protocol in a specialized non-ICU liver unit barring other indications for ICU transfer.