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# Norepinephrine ## Overview Norepinephrine is a potent catecholamine with primary alpha-1 adrenergic agonist activity (vasoconstriction) and moderate beta-1 adrenergic activity (inotropy). It is the first-line vasopressor for septic shock. ## Primary Indications * Acute hypotension (septic, cardiogenic, or vasodilatory shock status post-resuscitation). * Cardiac arrest (rarely used as a primary agent). ## Adult Dosing * **Initial:** 0.05 to 0.1 mcg/kg/min (or 5–30 mcg/min) via continuous IV infusion. * **Titration:** Titrate by 0.05–0.1 mcg/kg/min every 2–5 minutes to achieve target Mean Arterial Pressure (MAP), typically ≥65 mmHg. * **Maintenance:** Usual range is 0.01 to 3.3 mcg/kg/min. * *Note: Dosing is highly dependent on institutional protocols and clinical severity.* ## Pediatric Dosing * **Continuous IV Infusion:** Start at 0.05 to 0.1 mcg/kg/min. * **Titration:** Increase in increments of 0.1 mcg/kg/min to adjust for hemodynamics. * **Maximum:** Generally up to 2 mcg/kg/min. Always verify pediatric concentrations to avoid infusion errors. ## Dose Adjustments * **Hepatic/Renal Impairment:** No specific dosage adjustments required, though patients may be more sensitive to hemodynamic effects. * **Weaning:** Taper infusion gradually to prevent sudden rebound hypotension. ## Contraindications * Hypersensitivity to norepinephrine or sulfites. * Hypotension due to uncorrected blood volume deficit (except as an emergency measure to maintain coronary/cerebral perfusion). ## Adverse Effects * **Common:** Arrhythmias (bradycardia or tachycardia), hypertension, headache, anxiety. * **Serious:** Tissue ischemia/necrosis (secondary to extravasation), mesenteric/peripheral ischemia, metabolic acidosis. ## Key Drug Interactions * **MAOIs/Linezolid:** May lead to severe, prolonged hypertensive crisis. * **Beta-blockers:** May result in unopposed alpha-adrenergic stimulation, leading to excessive vasoconstriction and severe hypertension. * **Tricyclic Antidepressants (TCAs):** Can potentiate the pressor response. ## Monitoring * **Continuous:** ECG monitoring (arrhythmia detection) and invasive blood pressure (A-line) preferred. * **Frequent:** Heart rate, respiratory rate, peripheral pulses, and perfusion status. * **Site:** Regularly inspect IV site for signs of extravasation. Use a central line whenever possible. ## Clinical Pearls * **Extravasation Management:** If extravasation occurs, stop the infusion immediately and infiltrate the site liberally with phentolamine (5–10 mg in 10 mL saline) as soon as possible to counteract alpha-mediated vasoconstriction. * **Stability:** Norepinephrine base is commonly dosed in mg/mL. Ensure the concentration matches local policy (e.g., 4 mg/250 mL or 8 mg/250 mL D5W). * **Shock State:** Norepinephrine should not be initiated until adequate fluid resuscitation has been attempted or is being concurrently managed. *** *Disclaimer: This information is for educational purposes only. Dosing protocols can vary significantly by institution and patient acuity. Always verify current prescribing information, institutional guidelines, and compatibility charts before administration.*