Hi all, CA-1 here. Had a discussion with a neurosurgery resident and thought I'd get some feedback here. 60 year old pt with CHF (EF 30%), HTN (baseline MAPs 130s), severe cervical spinal stenosis, coming in for c-spine decompression. We do a pre-induction a-line and induce with etomidate. Pressures are stable. Intra-op monitoring so we're running TIVA (propofol, remifentanil, ketamine (b/c of history of chronic pain). I run a phenylephrine infusion to keep her around her baseline MAP (per neurosurgery attending request) and neurosurgery resident says I should be using norepi because that's what they use in the ICU. His argument is that norepi will increase contractility in this patient with low EF while phenylephrine is only increasing afterload - which makes sense. However, my argument back to him was that I'm keeping her MAP at baseline and that norepi will also increase heart rate via stimulation of beta-1 receptors and that will contribute more to myocardial oxygen demand than just some increased afterload to overcome the vasodilation from prop and remi infusions (which is the real cause of her hypotension and not a further reduction in EF). I could be wrong though! I kept the phenylephrine infusion and patient did well. What are your thoughts? Do you feel strongly one way or another in this patient with an EF of 30%?