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# Norepinephrine (Noradrenaline)
## Overview
Norepinephrine is a potent catecholamine with primary alpha-1 adrenergic activity (vasoconstriction) and moderate beta-1 adrenergic activity (inotropy). It is the first-line vasopressor for septic shock.
## Primary Indications
* Acute hypotensive states (e.g., septic, cardiogenic, or distributive shock).
* Adjunctive therapy in cardiac arrest.
## Adult Dosing
* **Initial Infusion:** 0.05–0.1 mcg/kg/min or 2–4 mcg/min (fixed rate).
* **Titration:** Titrate by 0.05–0.1 mcg/kg/min or 1–2 mcg/min every 2–5 minutes to achieve target mean arterial pressure (MAP).
* **Maintenance:** Typical range is 0.01–3 mcg/kg/min.
* **Maximum:** No formal absolute maximum; however, escalating doses reflect refractory shock and require consideration of vasopressin or corticosteroid adjuncts.
## Pediatric Dosing
* **Initial Infusion:** 0.05–0.1 mcg/kg/min.
* **Titration:** Titrate by 0.05 mcg/kg/min increments to achieve age-appropriate blood pressure/perfusion goals.
* **Maximum:** Up to 1–2 mcg/kg/min may be used in refractory cases.
## Dose Adjustments
* **Hepatic/Renal Impairment:** No specific adjustments recommended, but use with caution due to metabolism by monoamine oxidase (MAO) and catechol-O-methyltransferase (COMT).
* **Local Protocol:** Always adhere to institutional infusion concentration standards (e.g., 4 mg/250 mL or 8 mg/250 mL D5W).
## Contraindications
* Hypersensitivity to norepinephrine or sulfites.
* Hypotension due to uncorrected blood volume deficit (except as emergency support during fluid resuscitation).
## Adverse Effects
* **Common:** Hypertension, headache, bradycardia (reflex).
* **Severe:** Tissue necrosis due to extravasation, cardiac arrhythmias, mesenteric or peripheral ischemia.
## Key Drug Interactions
* **MAO Inhibitors/TCAs:** May cause severe, prolonged hypertension.
* **Beta-Blockers:** May lead to excessive vasoconstriction and reflex bradycardia.
* **Halogenated Anesthetics:** Increased risk of ventricular arrhythmias.
## Monitoring
* **Continuous arterial pressure monitoring:** Highly recommended for titration.
* **Perfusion parameters:** Monitor urine output, serum lactate, and capillary refill.
* **IV site:** Inspect frequently for signs of extravasation. If extravasation occurs, consider phentolamine infiltration.
## Clinical Pearls
* **Preferred Access:** Administer through a large-bore central venous catheter to reduce extravasation risk. Peripheral administration is acceptable in large veins for short durations if central access is delayed.
* **Goal:** Target a MAP of 65 mmHg in most shock states unless clinical judgment necessitates higher values.
* **Compatibility:** Must be administered in D5W or D5/NS. Adheres to plastic bags; infusion sets should be primed with the drug.
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**Educational Disclaimer:** This information is for educational purposes for healthcare professionals. Dosing protocols may vary significantly by institution. Always verify concentrations, compatibility, and patient-specific contraindications via your hospital’s pharmacy department or current clinical guidelines before administration.
