norepinephrine

Therapeutic Classification: vasopressors

High Alert

Severe acute hypotension.

Stimulates alpha-adrenergic receptors located mainly in blood vessels, causing constriction of both capacitance and resistance vessels.
Also has minor beta-adrenergic activity (myocardial stimulation).

Therapeutic effects:

Increased BP.
Increased cardiac output.

Absorption: IV administration results in complete bioavailability.

Distribution: Concentrates in sympathetic nervous tissue. Does not cross the blood-brain barrier.

Metabolism/Excretion: Taken up and metabolized rapidly by sympathetic nerve endings.

Half-Life: 2.5 min.

(effects on BP)

ROUTE	ONSET	PEAK	DURATION
IV	immediate	rapid	1–2 min

Contraindicated in:

Vascular, mesenteric, or peripheral thrombosis;
Hypoxia;
Hypercarbia;
Hypotension secondary to hypovolemia (without appropriate volume replacement);
Hypersensitivity to bisulfites.

Use Cautiously in:

Hypertension;
Hyperthyroidism;
Cardiovascular disease;
OB: May ↓ uterine blood flow in pregnancy;
Lactation: Safety not established in breastfeeding.

CV: arrhythmia, bradycardia, chest pain, hypertension

Endo: hyperglycemia

F and E: metabolic acidosis

GU: ↓urine output, renal failure

Local: phlebitis

Neuro: anxiety, dizziness, headache, insomnia, restlessness, tremor, weakness

Resp: dyspnea

Misc: fever

Drug-drug:

Cyclopropane or halothane anesthesia, digoxin, doxapram, or local use of cocaine may ↑ myocardial irritability.
Use with MAO inhibitors or tricyclic antidepressants may result in severe hypertension.
Alpha-adrenergic blockers can prevent pressor response.
Beta blockers may exaggerate hypertension or block cardiac stimulation.
Ergot alkaloids (ergotamine, methylergonovine, or oxytocin) may result in enhanced vasoconstriction and hypertension.

IV (Adults ): 0.5–1 mcg/min initially, followed by maintenance infusion of 2–12 mcg/min titrated by BP response (average rate 2–4 mcg/min, up to 30 mcg/min for refractory shock have been used).
IV (Children ): 0.1 mcg/kg/min initially; may be followed by infusion titrated to BP response, up to 1 mcg/kg/min.

(Generic available)

Premixed infusion: 4 mg/250 mL D5W or 0.9% NaCl; 8 mg/250 mL D5W or 0.9% NaCl; 16 mg/250 mL 0.9% NaCl
Solution for injection: 1 mg/mL

Monitor BP every 2–3 min until stabilized and every 5 min thereafter. Systolic BP is usually maintained at 80–100 mm Hg or 30–40 mm Hg below the previously existing systolic pressure in previously hypertensive patients. Continue to monitor BP frequently for hypotension following discontinuation of norepinephrine.
ECG should be monitored continuously. Central venous pressure, intra-arterial pressure, pulmonary artery diastolic pressure, pulmonary capillary wedge pressure, and cardiac output may also be monitored.
Monitor urine output and notify health care provider if it ↓ to <30 mL/hr.
Assess IV site frequently during infusion. If prolonged therapy is required or if blanching along the course of the vein occurs, change injection sites to provide relief from vasoconstriction.

Toxicity and Overdose:

If overdose occurs, discontinue norepinephrine and administer fluid and electrolyte replacement therapy. An alpha-adrenergic blocking agent may be administered IV to treat hypertension.

High Alert: Vasoactive medications are inherently dangerous. Have 2nd practitioner independently check original order, dose calculations, and infusion pump programming. Establish maximum dose limits. Norepinephrine overdose can result in severe peripheral vasoconstriction with resultant ischemia and necrosis of peripheral tissue. Assess peripheral circulation frequently.
Correct volume depletion, if possible, prior to initiation.
- May deplete plasma volume and cause ischemia of vital organs, resulting in hypotension when discontinued, if used for prolonged periods. Prolonged or large doses may also ↓ cardiac output.
- Infusion should be discontinued gradually, upon adequate tissue perfusion and maintenance of BP, to prevent hypotension. Do not resume therapy unless systolic BP falls to 70–80 mm Hg.

IV Administration:

Norepinephrine is a vesicant. Central line administration is preferred; extravasation may cause severe ischemic necrosis. If central line is not available, may administer for <72 hr through a peripheral IV catheter placed in a large vein at a proximal site (e.g., in or proximal to antecubital fossa). May also administer through a midline catheter. If extravasation occurs, immediately stop infusion. Leave needle/cannula in place temporarily but do not flush the line. Gently aspirate extravasated solution; then remove needle/cannula. Elevate patient's extremity and apply dry warm compresses. Initiate phentolamine antidote for refractory cases in addition to supportive management. For phentolamine, dilute 5–10 mg in 10 mL of 0.9% NaCl and administer SUBQ into extravasation site as soon as possible after extravasation; if IV catheter remains in place, administer initial dose IV through the infiltrated catheter. May repeat in 60 min if patient remains symptomatic. Nitroglycerin 2% topical ointment (1-inch strip applied to site of ischemia to cover affected area; may repeat every 8 hr as necessary) or terbutaline may be used as alternatives to phentolamine. For terbutaline, for large areas of extravasation, dilute 1 mg in 10 mL of 0.9% NaCl and administer SUBQ into extravasation site; may repeat in 15 min if necessary; for small areas of extravasation, dilute 1 mg in 1 mL of 0.9% NaCl and administer 0.5 mg (0.5 mL) SUBQ into extravasation site; may repeat in 15 min if necessary.
Continuous Infusion: Diluent: Dilute 4 mg in 1000 mL of D5W, D5/0.9% NaCl, or 0.9% NaCl. Concentration: 4 mcg/mL. Solution is colorless. Do not use discolored solutions (pink, yellow, brown) or those containing a precipitate. Solution is stable for 24 hr at room temperature. Protect from light.
Rate: Titrate infusion rate according to patient response, using slowest possible rate to correct hypotension.
Y-Site Compatibility:
- alemtuzumab
- amikacin
- anidulafungin
- argatroban
- arsenic trioxide
- ascorbic acid
- atracurium
- atropine
- aztreonam
- benztropine
- bivalirudin
- bleomycin
- bumetanide
- buprenorphine
- butorphanol
- calcium chloride
- calcium gluconate
- cangrelor
- carboplatin
- carmustine
- caspofungin
- cefazolin
- cefiderocol
- cefotaxime
- cefotetan
- cefoxitin
- ceftaroline
- ceftazidime
- ceftazidime/avibactam
- ceftobiprole
- ceftolozane/tazobactam
- ceftriaxone
- cefuroxime
- chloramphenicol
- chlorpromazine
- cisatracurium
- cisplatin
- clindamycin
- cyanocobalamin
- cyclophosphamide
- cyclosporine
- cytarabine
- dactinomycin
- daptomycin
- daunorubicin
- dexamethasone
- dexmedetomidine
- dexrazoxane
- digoxin
- diltiazem
- diphenhydramine
- dobutamine
- docetaxel
- dopamine
- doxycycline
- doxorubicin liposomal
- enalaprilat
- ephedrine
- epinephrine
- epirubicin
- epoetin alfa
- eravacycline
- ertapenem
- erythromycin
- esmolol
- etoposide
- etoposide phosphate
- famotidine
- fentanyl
- fluconazole
- fludarabine
- fosphenytoin
- gemcitabine
- gentamicin
- glycopyrrolate
- granisetron
- heparin
- hydrocortisone
- hydromorphone
- idarubicin
- ifosfamide
- imipenem/cilastatin
- imipenem/cilastatin/relebactam
- irinotecan
- isavuconazonium
- isoproterenol
- ketorolac
- labetalol
- letermovir
- leucovorin
- levetiracetam
- levofloxacin
- lidocaine
- linezolid
- lorazepam
- magnesium sulfate
- mannitol
- meperidine
- meropenem
- meropenem/vaborbactam
- mesna
- methadone
- methotrexate
- methylprednisolone
- metoclopramide
- metoprolol
- metronidazole
- micafungin
- midazolam
- milrinone
- minocycline
- mitoxantrone
- morphine
- moxifloxacin
- multivitamins
- mycophenolate
- nafcillin
- nalbuphine
- naloxone
- nicardipine
- nitroglycerin
- nitroprusside
- octreotide
- ondansetron
- oritavancin
- oxacillin
- oxaliplatin
- oxytocin
- paclitaxel
- palonosetron
- pamidronate
- papaverine
- pemetrexed
- penicillin G
- pentamidine
- phentolamine
- phenylephrine
- phytonadione
- piperacillin/tazobactam
- plazomicin
- posaconazole
- potassium acetate
- potassium chloride
- procainamide
- prochlorperazine
- promethazine
- propofol
- propranolol
- protamine
- pyridoxine
- remifentanil
- succinylcholine
- sufentanil
- tacrolimus
- tedizolid
- telavancin
- theophylline
- thiamine
- thiotepa
- tigecycline
- tirofiban
- tobramycin
- topotecan
- vancomycin
- vasopressin
- vecuronium
- verapamil
- vinblastine
- vincristine
- vinorelbine
- voriconazole
- zoledronic acid
Y-Site Incompatibility:
- aminophylline
- amphotericin B deoxycholate
- azathioprine
- dacarbazine
- dantrolene
- diazepam
- folic acid
- foscarnet
- ganciclovir
- gemtuzumab ozogamicin
- indomethacin
- mitomycin
- pentobarbital
- phenobarbital
- phenytoin
- sodium bicarbonate
- trimethoprim/sulfamethoxazole

Explain purpose of norepinephrine to patient.
Instruct patient to report headache, dizziness, dyspnea, chest pain, or pain at infusion site promptly.
Rep: Advise women of reproductive potential to notify health care provider if pregnancy is planned or suspected or if breastfeeding.

Increased BP.
Increased cardiac output.

NDC Code

43742- Deseret Biologicals, Inc.
- 43742-1489- Norepinephrine
  - 43742-1489-1- 30 mL in 1 BOTTLE, DROPPER (43742-1489-1)

43857- BioActive Nutritional, Inc.
- 43857-0161- Norepinephrine
  - 43857-0161-1- 30 mL in 1 BOTTLE, DROPPER (43857-0161-1)

43857- BioActive Nutritional, Inc.
- 43857-0260- Norepinephrine
  - 43857-0260-1- 30 mL in 1 BOTTLE, DROPPER (43857-0260-1)

44911- Energique, Inc.
- 44911-0499- Norepinephrine Phenolic
  - 44911-0499-1- 30 mL in 1 BOTTLE, DROPPER (44911-0499-1)

44911- Energique, Inc.
- 44911-0669- Norepinephrine Phenolic
  - 44911-0669-1- 60 mL in 1 BOTTLE, DROPPER (44911-0669-1)

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Indications ⬆ ⬇

Action ⬆ ⬇

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Time/Action Profile ⬆ ⬇

Contraind./Precautions ⬆ ⬇

Adv. Reactions/Side Effects ⬆ ⬇

Interactions ⬆ ⬇

Route/Dosage ⬆ ⬇

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Assessment ⬆ ⬇

Implementation ⬆ ⬇

Patient/Family Teaching ⬆ ⬇

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US Brand Names ⬆ ⬇

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