Norepinephrine
Norepinephrine bitartrate
Brand names:Levophed
A potent alpha-1 and beta-1 adrenergic agonist used as the first-line vasopressor for septic shock, distributive shock, and refractory hypotension from various causes. Norepinephrine increases vascular tone and modestly increases cardiac output, raising mean arterial pressure to support organ perfusion. The Surviving Sepsis Campaign designates norepinephrine as the initial vasopressor of choice.
Pharmacology and Actions
Strong alpha-1 adrenergic agonism produces peripheral vasoconstriction, increasing systemic vascular resistance. Moderate beta-1 agonism increases heart rate and myocardial contractility. The net effect is increased mean arterial pressure with maintained or increased cardiac output. Less tachycardia and arrhythmogenic effect than dopamine or epinephrine at equivalent vasopressor doses.
Indications
- Septic shock not responding to fluid resuscitation alone (first-line vasopressor)
- Distributive shock from anaphylaxis (second-line after epinephrine)
- Neurogenic shock
- Post-cardiac arrest hypotension
- Refractory hypotension during anesthesia
- Cardiogenic shock with hypotension (adjunct to inotrope therapy)
Absolute Contraindications
- Profound hypovolemia (treat volume deficit first; norepinephrine in hypovolemic shock causes severe vasoconstriction without circulating volume to support)
- Mesenteric or peripheral vascular thrombosis
- Concurrent cyclopropane or halothane anesthesia (legacy contraindication, agents largely obsolete)
Precautions and Side Effects
Severe peripheral and visceral vasoconstriction can cause limb ischemia, mesenteric ischemia, and acute kidney injury. Extravasation causes severe tissue necrosis - central venous administration strongly preferred; peripheral administration acceptable in emergency for limited duration. Bradycardia reflexively in response to vasoconstriction in some patients. Hypertension if over-titrated. Arrhythmias less common than with dopamine or epinephrine.
Adult Dosing
Pediatric Dosing
0.05 to 0.1 mcg/kg/min initial, titrate to MAP target by age. Usual range 0.05 to 2 mcg/kg/min. Pediatric Surviving Sepsis Campaign considers norepinephrine first-line in fluid-refractory septic shock.
Pharmacokinetics
Peak Effect: 1 to 2 minutes
Duration: 1 to 2 minutes after infusion stops (very short half-life)
Storage and Handling
Refrigerate at 2 to 8 degrees C until use; room temperature stable for 24 hours once dispensed. Protect from light. Pre-mixed bags typically 4 mg in 250 mL D5W (16 mcg/mL) or 8 mg in 250 mL D5W (32 mcg/mL). Discoloration (brown or pink) indicates degradation - do not use.
Reconstitution:
Standard concentration 4 mg/250 mL D5W or normal saline (16 mcg/mL). Concentrated 8 mg/250 mL (32 mcg/mL) for fluid-restricted patients or sustained high-dose requirements.
TCCC and TECC Role
Not a TCCC core formulary medication. Used in Prolonged Casualty Care, role 2 and above, and hospital settings. CMC and CPP tier providers may administer norepinephrine in extended care scenarios for septic shock or distributive shock not responsive to fluids. Continuous infusion requirement and central access preference make field use difficult outside of austere medical care environments.
Norepinephrine is what you reach for when the patient is fluid-resuscitated and still hypotensive. The trauma patient in hemorrhagic shock is volume-down and needs blood, not vasopressors; vasopressors in hypovolemic shock without volume replacement worsen tissue perfusion. The patient with septic shock or distributive shock has plenty of intravascular volume relative to a vasodilated vascular bed and benefits from vasoconstriction. The distinction matters operationally because a misapplied norepinephrine drip in a bleeding trauma patient is harmful. Field administration requires continuous infusion capability and ideally central venous access; peripheral IV use is acceptable in emergencies but extravasation produces severe tissue necrosis.
Using norepinephrine in inadequately fluid-resuscitated hypovolemic shock. The MAP may come up, but tissue perfusion suffers because vasoconstriction is occurring without circulating volume to perfuse the tissues. The correct sequence is volume first (blood for hemorrhage, crystalloid then balanced for sepsis), then vasopressor if MAP remains inadequate. The other common mistake is peripheral administration without monitoring for extravasation. Norepinephrine extravasation causes severe ischemic necrosis; phentolamine local infiltration is the antidote if extravasation occurs.
This drug profile is provided as educational reference material for trained medical providers. It is not medical advice, not a substitute for formal training, and not a substitute for current published guidelines or medical direction.
Drug administration is governed by your scope of practice, agency standing orders, medical director protocols, and applicable state and federal regulations. Controlled substances are subject to additional handling, accountability, and documentation requirements per DEA and state law. Always verify dosing, indications, contraindications, and route of administration against current published guidelines and your local protocols before administration.
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Drug information evolves. Last reviewed dates and source citations are provided for each entry. Confirm currency against the cited source before clinical use.
Penn Tactical Solutions publishes this reference for educational purposes. PTS does not provide medical direction and does not assume responsibility for clinical decisions made in the field. Clinical responsibility rests with the administering provider, their medical director, and their agency.
Educational reference for trained medical providers. Not medical advice. Not a substitute for formal training, current published guidelines, or medical direction. Drug administration is governed by your scope of practice, agency standing orders, medical director protocols, and applicable state and federal regulations. Controlled substances require additional storage, accountability, and documentation per DEA and state law.
In a medical emergency, call 911. This reference is not a substitute for emergency medical services.
Verify dosing, indications, and contraindications against current published guidelines and your local protocols before administration. Confirm content currency against the source citation. Penn Tactical Solutions does not provide medical direction. Clinical responsibility rests with the administering provider, their medical director, and their agency.
Norepinephrine
| IV/IO | Initial infusion 0.05 to 0.1 mcg/kg/min (or 2 to 4 mcg/min in adults), titrate to MAP target (typically greater than or equal to 65 mmHg in sepsis). Usual range 0.05 to 2 mcg/kg/min. Doses above 1 mcg/kg/min suggest severe vasoplegia and may warrant addition of second agent (vasopressin, epinephrine). (1 to 2 minutes) |
| IM | None (not given IM) (None) |
| IN | None (None) |
| PO | None (None) |