Norepinephrine

General

Type: Vasopressors
Dosage Forms: IV
Common Trade Names: Levophed

Adult Dosing

Dosing

Usual Adult Dose for Hypotension. Initial dose: 2 to 4 mcg/min with titration to 25 mcg/min

Based on Glomerular Filtration Rate [GFR (ml/min)]

<10: 0.2mcg/kg/min
10-40: 0.3mcg/kg/min
>40-50: 0.4mcg/kg/min

For CVVHD: dose at 0.4mcg/kg/min
For HD: dose 0.2mcg/kg/min

Rate of Titration

Q2-5 min

Pediatric Dosing

Hypotension/Shock
- IV Infusion: Initiate at 0.05-0.1mcg/kg/min, titrate to effect, usual max dose 2mcg/kg/min

Special Populations

Pregnancy Rating: C
Lactation: Unknown if excreted in breast milk
Renal Dosing
- Adult
- Pediatric
Hepatic Dosing
- Adult
- Pediatric

Contraindications

Allergy to class/drug

Adverse Reactions

If extravasation occurs use phentolamine 0.1 to 0.2mg/kg (maximum dose 10mg) subcutaneous in affected site^[1]^[2]
- Consult plastic/general surgery service to follow the patient and eval for need for intervention

Cardiovascular: Bradycardia, Arrhythmia, Cardiomyopathy
CNS Anxiety, Headache
Respiratory: Dyspnea

Pharmacology

Half-life: Effects for 1-2min
Metabolism: In the blood via COMT and MAO
Excretion: Renal
Mechanism of Action:

Primary Receptor

α₁ >> β₁

Relative Effects

↑↑↑SVR
↑HR
↑SV

Notes

More potent vasoconstrictor than dopamine and phenylephrine.

Indication

Septic shock (1st line)
Cardiogenic shock:
- If marked hypotension (SBP <70)
- If used with dobutamine

Indications by Condition

The following table is automatically generated from disease/condition pages across WikEM.

Indication	Dose	Context	Route	Population
Calcium channel blocker toxicity	Start 2 mcg/min, uptitrate rapidly to MAP ≥65	Vasopressor (agent of choice)	IV drip	Adult
Sepsis (main)	0.1-1 mcg/kg/min (typical start 5-20 mcg/min)	1st line vasopressor	IV drip	Adult
Vasopressors	2-5 mcg/min (0.01-0.03 mcg/kg/min), max 0.5-1 mcg/kg/min	1st line vasopressor	IV drip	Adult
Vasopressors	0.05-0.4mcg/kg/min (start 5-15mcg/min)	First-line vasopressor for septic shock	IV	Adult

External Links

EMCRIT Podcast - Peripheral Vasopressors

References

↑ ZUCKER G. et al. Treatment of shock and prevention of ischemic necrosis with levarterenol-phentolamine mixtures. Circulation. 1960 Nov;22:935-7.
↑ PELNER L. et al. The problem of levarterenol (norepinephrine) extravasation an experimental study.. Am J Med Sci. 1958 Dec;236(6):755-66

Authors:

[1] ZUCKER G. et al. Treatment of shock and prevention of ischemic necrosis with levarterenol-phentolamine mixtures. Circulation. 1960 Nov;22:935-7.

[2] PELNER L. et al. The problem of levarterenol (norepinephrine) extravasation an experimental study.. Am J Med Sci. 1958 Dec;236(6):755-66

[1]

[2]