Learning Center/Pharmacology/Norepinephrine

Norepinephrine

Levophed

vasopressorIV (central line preferred; peripheral for short-term initiation)Onset: 1–2 minutesDuration: Minutes; constant infusion required

Mechanism of Action

Endogenous catecholamine. Predominantly alpha-1 and alpha-2 agonist → peripheral vasoconstriction → increased MAP. Minimal beta-2 effects (no bronchodilation). Some beta-1 effects (inotropic) at high doses.

Dosing

Adult

0.01–3 mcg/kg/min IV; titrate to MAP ≥65 mmHg. Start: 0.1–0.2 mcg/kg/min

Indications

Septic shock (first-line vasopressor per Surviving Sepsis Campaign)
Distributive shock (anaphylactic, neurogenic)
Hypotension refractory to fluids

Contraindications

Hypovolemia (must resuscitate first)
Mesenteric/peripheral vascular thrombosis
Pregnancy (reduces uterine blood flow)

Side Effects

Hypertension
Reflex bradycardia
Peripheral ischemia / digital necrosis (high doses, prolonged)
Tissue necrosis with extravasation
Arrhythmias (rare at therapeutic doses)

Monitoring Parameters

Blood pressure (continuous arterial line preferred)
Heart rate
Urine output
Peripheral perfusion / skin color
Lactate (clearance)
IV site for extravasation (use central line)

Drug Interactions

MAOIs (severe hypertension)
TCAs (potentiated pressor response)
Beta-blockers (unopposed alpha → exaggerated hypertension)
Halothane (arrhythmias)

Clinical Pearls

First-line vasopressor for septic shock (Surviving Sepsis Campaign 2021)
Administer via central line (extravasation causes tissue necrosis)
Extravasation antidote: phentolamine (alpha-blocker) injected locally
Does not cause tachycardia (unlike dopamine) — preferred in patients with tachyarrhythmias
Often combined with vasopressin to reduce norepinephrine requirements

Mnemonic

💡 NorEPINEPHrine: NOrmal pressure without tachycardia = #1 septic shock pressor

NBRC High-Yield

First-line vasopressor for septic shock
Alpha-1 dominant: vasoconstriction, raises MAP
Central line required (extravasation → tissue necrosis)
Does NOT cause significant tachycardia
Phentolamine for extravasation treatment

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Clinical Pearls

First-line vasopressor for septic shock (Surviving Sepsis Campaign 2021)

Administer via central line (extravasation causes tissue necrosis)

Extravasation antidote: phentolamine (alpha-blocker) injected locally

Does not cause tachycardia (unlike dopamine) — preferred in patients with tachyarrhythmias

Often combined with vasopressin to reduce norepinephrine requirements