Norepinephrine

Aliases: Levophed 

Indications: Hypotension, septic shock, shock persisting after adequate fluid volume replacement        

Contraindications: Known allergy, hypovolemic shock from hemorrhage 

Concentrations: 

Infusion: 16-64 mcg/mL

Dosing

Adult:

Indication	Dose	Route	Note
-Non-hemorrhagic Hypotension  -Unstable Bradycardia  -Persistent shock after volume replacement	2-20 mcg/min	Infusion	Titrate to MAP > 65 mmHg

Pediatric:

Indication	Dose	Route	Note
None

Precautions: Ensure patent IV/IO access throughout the infusion. 

Adverse/Side Effects:

Systemic: Ischemic injury due to potent vasoconstrictor action and tissue hypoxia. 

Cardiovascular: Bradycardia, probably as a reflex result of a rise in blood pressure, arrhythmias, tachycardia 

Nervous: Anxiety, transient headache. 

Respiratory: Respiratory difficulty. 

Skin and Appendages: Extravasation necrosis at injection site. Gangrene of extremities has been rarely reported. Overdoses or conventional doses in hypersensitive persons (e.g., hyperthyroid patients) cause severe hypertension with violent headache, photophobia, stabbing retrosternal pain, pallor, intense sweating, and vomiting. 

Class: Sympathomimetic: Alpha/Beta agonist  

Mechanism of Action: Norepinephrine acts predominantly on alpha-adrenergic receptors to produce constriction of resistance and capacitance vessels, thereby increasing systemic blood pressure and coronary artery blood flow. Norepinephrine also acts on beta1-receptors, although quantitatively less than either epinephrine or isoproterenol. In relatively lower doses, the cardiac-stimulant effect of norepinephrine is predominant; with larger doses, the vasoconstrictor effect predominates. Like epinephrine, norepinephrine has direct agonist effects on effector cells that contain alpha and beta receptors. 

Onset of Action	Peak Effect	Duration of Action
Rapid	1-2 minutes	1-2 minutes