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# Norepinephrine
## Overview
Norepinephrine is a potent vasopressor and inotropic agent that acts on alpha-1 adrenergic receptors causing vasoconstriction and beta-1 adrenergic receptors increasing heart rate and contractility.
## Primary Indications
* Management of severe hypotension and shock, particularly septic shock and cardiogenic shock, unresponsive to adequate fluid resuscitation.
## Adult Dosing
* **Initial Dose:** 0.01 to 0.02 mcg/kg/min IV infusion.
* **Titration:** Titrate infusion rate every 2-5 minutes to achieve target mean arterial pressure (MAP), typically 65 mmHg or higher. Doses can be increased by 0.01 to 0.02 mcg/kg/min increments.
* **Maximum Dose:** Doses up to 0.5 mcg/kg/min may be required in severe cases. Local protocols may specify maximum doses.
## Pediatric Dosing
* **Initial Dose:** 0.05 to 0.1 mcg/kg/min IV infusion.
* **Titration:** Titrate to achieve target MAP based on age (e.g., age + 2 years x 2 mmHg for infants and children, or 65 mmHg for adolescents). Doses can be increased by 0.05 to 0.2 mcg/kg/min increments.
* **Maximum Dose:** Doses up to 1-2 mcg/kg/min may be required. Refer to pediatric resuscitation guidelines and local protocols.
## Dose Adjustments
* No specific dose adjustments are typically required for renal or hepatic impairment, as the drug is primarily metabolized in the liver and excreted by the kidneys. Dosing is driven by hemodynamic response.
## Contraindications
* Hypersensitivity to norepinephrine.
* Generally not recommended in patients with profound hypovolemia prior to volume resuscitation.
## Adverse Effects
* **Cardiovascular:** Hypertension, reflex bradycardia, arrhythmias, peripheral ischemia, extravasation leading to tissue necrosis.
* **Other:** Headache, anxiety, dizziness, tremor, dyspnea.
## Key Drug Interactions
* **Anesthetics:** May potentiate arrhythmias.
* **Beta-blockers:** May antagonize beta-mediated effects of norepinephrine.
* **MAO Inhib
