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# Norepinephrine
## Overview
Norepinephrine is a potent alpha-1 adrenergic agonist and a weaker beta-1 adrenergic agonist. It causes vasoconstriction, leading to increased systemic vascular resistance and blood pressure.
## Primary Indications
* Treatment of hypotension in shock states, particularly septic shock and cardiogenic shock.
* Restoration and maintenance of blood pressure.
## Adult Dosing
* **Initial Infusion:** 2 to 10 mcg/minute.
* **Titration:** Titrate infusion rate to achieve target mean arterial pressure (MAP), often 65-70 mmHg, or as per local protocol. Doses up to 30 mcg/minute may be required.
* **Administration:** Administer via a central venous catheter. Peripheral administration is generally not recommended due to the risk of extravasation and tissue necrosis.
## Pediatric Dosing
* **Initial Infusion:** 0.05 to 0.1 mcg/kg/minute.
* **Titration:** Titrate infusion rate to achieve target MAP (e.g., target systolic blood pressure >5th percentile for age, or as per local protocol). Doses up to 2 mcg/kg/minute may be required.
* **Administration:** Central venous catheter is preferred.
## Dose Adjustments
* No specific dose adjustments for renal or hepatic impairment are established, but close monitoring of response and potential for accumulation is warranted.
## Contraindications
* Hypersensitivity to norepinephrine.
* Hypotension due to pure hypovolemia (volume resuscitation should be attempted first).
* Use during cyclopropane or halogenated hydrocarbon anesthesia (may cause severe hypertension and arrhythmias).
## Adverse Effects
* **Common:** Hypertension, bradycardia, peripheral ischemia, arrhythmias, headache, anxiety, reduced blood flow to organs (e.g., kidneys, splanchnic bed).
* **Serious:** Extravasation leading to tissue necrosis, myocardial infarction, stroke, severe hypertension.
## Key Drug Interactions
* **MAO Inhibitors:** Potentiate pressor response; avoid concurrent use or allow a drug-free interval of at least 14 days.
* **Tricyclic Antidepressants (TCAs):** May potentiate pressor response.
* **Beta-Blockers:** Can cause unopposed alpha-adrenergic stimulation leading to severe hypertension.
* **Ergot Alkaloids:** May potentiate pressor effect.
* **Oxytocic Drugs:** May cause severe persistent hypertension.
* **Anesthetics (e.g., cyclopropane, halothane):** Increased risk of arrhythmias.
## Monitoring
* Continuous hemodynamic monitoring (arterial line for MAP).
* Heart rate and rhythm.
* Urine output.
* Peripheral perfusion.
* Infusion site for signs of extravasation.
## Clinical Pearls
* Norepinephrine is a first-line agent for septic shock refractory to adequate fluid resuscitation.
* Central venous access is essential for safe administration.
* Have phentolamine readily available to treat extravasation.
* Gradually taper infusion to avoid rebound hypotension.
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***Disclaimer:** This information is intended for clinical pharmacists and should not replace a thorough review of the full prescribing information and current clinical guidelines. Always verify current drug information with official sources before use.*
