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# Norepinephrine (Levophed)
## Overview
Norepinephrine is a potent vasopressor and inotropic agent, primarily acting as an α1-adrenergic agonist with moderate β1 activity. It causes vasoconstriction and increases blood pressure with variable effects on heart rate. Used primarily in distributive shock (e.g., septic shock).
## Primary Indications
- First-line vasopressor for septic shock (Surviving Sepsis Campaign)
- Refractory hypotension from other shock states (e.g., cardiogenic, neurogenic)
- Adjunct in hypotension during anesthesia or overdose
## Adult Dosing
- **Initial**: 0.1–0.5 mcg/kg/min IV, titrated to goal MAP (usually ≥65 mmHg)
- **Typical range**: 0.05–1.0 mcg/kg/min; higher doses (up to 3 mcg/kg/min) may be used per local protocol
- **Maximum**: No absolute max; upper limit varies (commonly 3 mcg/kg/min)
- **Administration**: Central line preferred; can be peripheral line (large vein) temporarily with extravasation risk
## Pediatric Dosing
- **Initial**: 0.05–0.1 mcg/kg/min IV/IO, titrate to effect
- **Usual range**: 0.1–1.0 mcg/kg/min; may increase to 2 mcg/kg/min in refractory shock
- **Maximum**: Not established; use caution above 1–2 mcg/kg/min
- **Administration**: Central line strongly preferred
## Dose Adjustments
- **Renal impairment**: No adjustment needed
- **Hepatic impairment**: No established adjustment; monitor closely
- **Elderly**: Start at lower end of range; increased sensitivity
## Contraindications
- Hypersensitivity to norepinephrine or sulfites (contains sodium bisulfite)
- Severe hypovolemia (correct volume first)
- Caution in: mesenteric or peripheral vascular ischemia, hyperthyroidism, hypertension, hypoxemia
## Adverse Effects
- **Common**: Hypertension, reflex bradycardia (from baroreceptor response), arrhythmias, anxiety
- **Serious**: Tissue ischemia/necrosis from extravasation (treat with phentolamine infiltration), decreased organ perfusion, ventricular arrhythmias
- **Rebound hypotension** with abrupt discontinuation
## Key Drug Interactions
- **MAOIs**: Potential for severe hypertensive crisis (avoid concurrent use)
- **Tricyclic antidepressants**: Potentiate pressor response
- **Beta-blockers**: Unopposed α1 activity → hypertension
- **Ergot alkaloids**: Synergistic vasoconstriction → ischemia risk
## Monitoring
- **Hemodynamics**: Continuous BP, HR, MAP goal; consider cardiac output monitoring
- **Local site**: Daily inspection for extravasation/ischemia
- **End-organ perfusion**: Urine output, lactate clearance, mental status
- **ECG**: For arrhythmias especially at higher doses
## Clinical Pearls
- **Taper gradually** to avoid rebound hypotension; do not stop abruptly
- **Correct hypovolemia** first; norepinephrine is not a volume substitute
- **Central line preferred** but peripheral administration (large vein, short duration) is allowed with close monitoring
- **Extravasation antidote**: Infiltrate phentolamine 5–10 mg in 10 mL NS subcutaneously within 12 hours
- **Concentration**: Standard is 4 mg/250 mL (16 mcg/mL) or 8 mg/250 mL (32 mcg/mL); follow local protocols
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**Disclaimer**: This information is for educational purposes. Dosing and administration vary by clinical context, local protocols, and institutional guidelines. Always verify current prescribing information, product labeling, and institutional policies before administering any medication.
