Norad%20%28norepinephrine%29

# Norad (norepinephrine) ## Overview - Potent alpha-1 agonist with beta-1 activity (minimal beta-2) - First-line vasopressor for septic shock (Surviving Sepsis Campaign) - Used for hypotension refractory to fluid resuscitation ## Primary Indications - Septic shock - Cardiogenic shock (with low SVR) - Hypotension during anesthesia/surgery - Neurogenic shock ## Adult Dosing - **Initiation**: 0.5–1 mcg/min IV - **Titration**: Increase by 0.5–1 mcg/min q5-10min to target MAP ≥65 mmHg - **Usual range**: 2–20 mcg/min - **Maximum**: No absolute max; higher doses (≥30 mcg/min) used temporarily but associated with increased adverse effects - *Exact dosing depends on local protocol and patient response* ## Pediatric Dosing - **IV infusion**: 0.05–0.1 mcg/kg/min, titrate to effect - **Maximum**: Usually up to 2 mcg/kg/min; no formal ceiling, but high doses signal poor prognosis - *Use central line when possible; peripheral access for short-term, dilute concentrations* ## Dose Adjustments - **Hepatic/renal impairment**: No specific adjustment needed (minimal hepatic metabolism) - **Elderly**: Start at low end of range, titrate cautiously ## Contraindications - Hypersensitivity - Hypotension from hypovolemia (correct volume first) - Severe peripheral vasoconstriction (e.g., Raynaud's) - Mesenteric or peripheral vascular thrombosis ## Adverse Effects - **Common**: Tachycardia, hypertension, arrhythmias, headache, anxiety - **Serious**: Tissue ischemia/necrosis with extravasation (treat with phentolamine), limb ischemia, bradycardia (reflex), reduced cardiac output at high doses ## Key Drug Interactions - **MAOIs, TCAs**: Potentiate hypertensive effect (use caution, reduce dose) - **Beta-blockers**: Unopposed alpha-activity → severe hypertension, bradycardia - **Ergot alkaloids**: Additive vasoconstriction - **Halogenated anesthetics**: Risk of ventricular arrhythmias ## Monitoring - **Continuous**: BP (arterial line preferred), HR, ECG (for arrhythmia) - **Peripheral perfusion**: Capillary refill, urine output, lactate clearance - **MAP target**: ≥65 mmHg (individualize) - **Extravasation**: Monitor infusion site hourly ## Clinical Pearls - **Central line preferred** due to vasoconstriction risk with peripheral access (acceptable short-term in large vein) - **Extravasation protocol**: Stop infusion, aspirate, infiltrate phentolamine 5–10 mg in 10–15 mL NS subcutaneously around site - **Taper slowly** to avoid rebound hypotension (half-life ~2 min) - **Not compatible** in same line with alkaline solutions (e.g., sodium bicarbonate) - First-line vasopressor in septic shock – start early after fluid resuscitation --- *This information is for educational purposes only. Always verify current prescribing information, local protocols, and manufacturer labeling before patient use. Dosing and indications may vary by institution and clinical scenario.*