A patient shows signs of anaphylaxis after contrast exposure and remains hypotensive despite fluid resuscitation. What should be initiated next?

In the case of a patient experiencing signs of anaphylaxis following contrast exposure, the primary concern is the management of their hemodynamic stability. Anaphylaxis can lead to widespread vasodilation and increased vascular permeability, resulting in hypotension that may not sufficiently respond to fluid resuscitation alone.

Initiating a norepinephrine infusion is appropriate in this scenario because it is a potent vasopressor that works by causing peripheral vasoconstriction and increasing systemic vascular resistance. As a result, it can effectively raise blood pressure and help stabilize the patient’s hemodynamics in the face of severe hypotension. Norepinephrine is commonly used in anaphylactic shock when fluid resuscitation is insufficient to address hypotension.

Other options like packed red blood cells, vasopressin infusion, and fresh frozen plasma are not the recommended immediate treatments in this situation. Packed red blood cells would not address the hypotension caused by anaphylaxis, and vasopressin does not typically play a primary role in anaphylactic shock management. Fresh frozen plasma would not be appropriate in this acute setting. Thus, norepinephrine is the first-line agent to manage persistent hypotension after fluid resuscitation in the context of anaphylaxis.