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# Norepinephrine (Noradrenaline)
## Overview
Norepinephrine is a potent catecholamine with alpha-1 agonist activity (vasoconstriction) and moderate beta-1 agonist activity (inotropy). It is the first-line vasopressor for septic shock.
## Primary Indications
* Acute hypotensive states (e.g., septic, cardiogenic, or neurogenic shock)
* Adjunct treatment of cardiac arrest
## Adult Dosing
* **Initial Infusion:** 0.01 to 0.05 mcg/kg/min IV.
* **Titration:** Titrate to achieve target MAP (usually 65 mmHg). Common clinical range is 0.01 to 3 mcg/kg/min.
* **Max Dose:** No absolute maximum; doses >1–3 mcg/kg/min are significantly associated with reflex bradycardia and tissue ischemia.
## Pediatric Dosing
* **Initial Infusion:** 0.05 to 0.1 mcg/kg/min IV.
* **Titration:** Titrate by 0.05–0.1 mcg/kg/min every 5–10 minutes based on clinical response.
* **Max Dose:** 1–2 mcg/kg/min.
## Dose Adjustments
* **Renal/Hepatic:** No formal dosage adjustments required.
* **Protocol:** Local institutional protocols/nursing guidelines dictate titration frequency and concentration requirements.
## Contraindications
* Hypersensitivity to norepinephrine.
* Hypotension due to uncorrected blood volume deficit (except as emergency interim therapy).
* Thrombosis (mesenteric or peripheral vascular).
## Adverse Effects
* **Extravasation:** Severe tissue necrosis and sloughing; strictly avoid peripheral administration if central access is feasible.
* **Cardiovascular:** Hypertension, reflex bradycardia, arrhythmias, myocardial ischemia.
* **Metabolic:** Lactic acidosis (secondary to splanchnic vasoconstriction).
## Key Drug Interactions
* **MAO Inhibitors/Antidepressants (TCAs):** Can cause severe, prolonged hypertension.
* **Beta-blockers:** May cause excessive hypertension and profound reflex bradycardia due to unopposed alpha-stimulation.
* **Halogenated hydrocarbons:** Increased risk of ventricular arrhythmias.
## Monitoring
* **Continuous:** Blood pressure (arterial line preferred), ECG (rate and rhythm), and oxygen saturation.
* **Clinical:** MAP, urine output, distal perfusion/extremity temperature, and lactate clearance.
* **Site:** Check infusion site hourly for signs of extravasation.
## Clinical Pearls
* **Extravasation Management:** If extravasation occurs, stop infusion, leave cannula in place, and infiltrate the area with **phentolamine** (alpha-adrenergic antagonist) as soon as possible.
* **Peripheral Administration:** Safe for short-term use in large veins (e.g., antecubital) if necessary, provided concentrations are dilute and the limb is monitored closely.
* **"Fluidize":** Ensure adequate intravascular volume expansion before or concurrently with initiation to maximize efficacy and prevent organ ischemia.
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*Disclaimer: This information is for educational purposes only. Clinical practice varies by institution; always consult your local formulary, hospital protocols, and the official manufacturer prescribing information before administration.*
