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# Norepinephrine ## Overview Norepinephrine is a potent catecholamine acting primarily on alpha-1 adrenergic receptors, causing peripheral vasoconstriction, and to a lesser extent on beta-1 adrenergic receptors, resulting in mild inotropic effects. ## Primary Indications * First-line vasopressor for septic shock. * Treatment of acute hypotensive states (e.g., cardiogenic or distributive shock). ## Adult Dosing * **Initial:** 0.01 – 0.05 mcg/kg/min or 2–4 mcg/min via continuous IV infusion. * **Titration:** Titrate by 0.05 – 0.1 mcg/kg/min every 3–5 minutes to achieve target mean arterial pressure (MAP) (typically >65 mmHg). * **Maintenance Range:** 0.01 – 3 mcg/kg/min (highly variable based on clinical status). * **Note:** Always consult local hospital protocols for specific concentration and titration parameters. ## Pediatric Dosing * **Continuous IV Infusion:** 0.05 – 1 mcg/kg/min. * **Titration:** Titrate to clinical effect (e.g., adequate perfusion, blood pressure for age). ## Dose Adjustments * **Renal/Hepatic Impairment:** No specific dose adjustments provided in labeling; however, clinical response should guide titration. * **Max Dose:** No absolute maximum; limited by patient tolerance (tachyarrhythmias, ischemia). ## Contraindications * Hypersensitivity to norepinephrine or any component of the formulation. * Mesenteric or peripheral vascular thrombosis (due to severe vasoconstriction). ## Adverse Effects * **Common:** Hypertension, headache, anxiety. * **Serious:** Tissue necrosis (if extravasation occurs), cardiac arrhythmias (bradycardia or tachycardia), limb ischemia, and metabolic acidosis secondary to peripheral hypoperfusion. ## Key Drug Interactions * **MAO Inhibitors/TCAs:** May cause severe, prolonged hypertension. * **Beta-Blockers:** May cause unopposed alpha-adrenergic vasoconstriction (severe hypertension). * **Halogenated Hydrocarbons (e.g., volatile anesthetics):** May sensitize the myocardium to arrhythmias. ## Monitoring * **Hemodynamics:** Continuous MAP monitoring via arterial line is strongly recommended. * **Access Site:** Ensure large-bore vein; monitor for extravasation (assess skin integrity frequently). * **Cardiac:** Continuous ECG monitoring for arrhythmias. * **Systemic:** Urine output and capillary refill to assess end-organ perfusion. ## Clinical Pearls * **Extravasation Management:** If extravasation occurs, discontinue infusion and infiltrate the site with phentolamine (5–10 mg in 10 mL saline) locally to neutralize vasoconstriction. * **Volume Status:** Pressors should ideally be initiated after or concurrent with appropriate fluid resuscitation in hypovolemic patients. * **Standardization:** Use centralized hospital standardized concentrations (e.g., 4 mg/250 mL or 8 mg/250 mL) to reduce medication errors. *** *Disclaimer: This information is for educational purposes and does not supersede local institutional protocols. Always consult current prescribing information and verify dosages with a clinician before administration.*