Pharm
Norepinephrine
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Norepinephrine
, Levarterenol, L-norepinephrine, Levonorepinephrine, Noradrenaline, Levophed
See Also
Epinephrine
Sympathomimetic Toxicity
Sympathetic Nervous System
Sympathomimetic
Alpha Adrenergic Receptor
Beta Adrenergic Receptor
Definitions
Norepinephrine
Natural
Catecholamine
, released from
Adrenal Medulla
as a stress response (along with
Epinephrine
)
Also the primary postganglionic
Neurotransmitter
of the
Sympathetic Nervous System
History
Ulf Von Euler won 1970 Nobel Prize for its discovery
Swedish Chemist also discovered Prostaglandins
Mechanism
Naturally occurring
Catecholamine
Potent
Alpha Adrenergic Receptor
Agonist
Potent arterial and venous
Vasocon
striction
Beta 1 Adrenergic Receptor
Agonist
Similar potency to
Epinephrine
Increases myocardial contractility
No
Beta 2 Adrenergic Receptor
Activity
Indications
Hemodynamically significant
Hypotension
Refractory to other
Sympathomimetic
amines
Useful in Low
Systemic Vascular Resistance
Septic Shock
Neurogenic Shock
Temporizing measure only
Relative Contraindications
Acute
Myocardial Infarction
Use as agent of last resort
Monitoring
Monitor
Blood Pressure
accurately
Consider
Arterial Line
with continuous monitoring
Blood Pressure
cuff monitoring every 5 minutes
Consider advanced hemodynamic monitoring
Cardiac Output
Pulmonary wedge pressure
Peripheral arterial resistance
Precautions
Maximize management of other
Hypotension
causes first
Maximize fluid
Resuscitation
in
Sepsis
Replace
Blood Product
s in
Trauma
Use with caution in
Myocardial Ischemia
Increases myocardial oxygen requirements
No compensatory increase in coronary perfusion
Observe for
Arrhythmia
s
Volume depleted patents
Limited myocardial reserve
Norepinephrine is safest to use via central venous catheter
However reliable large bore peripheral IV may be used safely with caution initially (e.g. first 24 hours)
Nguyen (2020) Am J Emerg Med +PMID: 31959524 [PubMed]
Extravasation may cause severe local tissue damage
Antidote for extravasation
Phentolamine 5-10 mg diluted in 10-15 ml NS
Infiltrate area of extravasation with Phentolamine
Preparation
Start with Norepinephrine (1 mg/ml) 4 ml ampule
Mix 4 ml Norepinephrine in 250 ml D5W or
Normal Saline
Final Concentration: 16 ug/ml Norepinephrine
Dosing
Infusion via Central Venous Catheter
Weight Based (preferred, adults)
Start at 0.05 mcg/kg/min
Unlikely to benefit from titration above 0.3 mcg/kg/min
Non-weight based
Start at 5 mcg/min (some recommend starting at 0.5 to 1.0 ug/min)
Typical dose range (adults): 2 to 30 mcg/min
Titrate to Systolic
Blood Pressure
over 90 mmHg
Average Adult Dose: 2 to 12 ug/min
Refractory
Shock
: up to 30 ug/min
References
McCollum in Herbert (2019) EM:Rap 19(7):4-6
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