What are the situations where norepinephrine (noradrenaline) drip is contraindicated or not useful?

From the Guidelines

Norepinephrine drips are contraindicated in several clinical situations, including hypovolemic shock, mesenteric or peripheral ischemia, pheochromocytoma, severe cardiac disease, and cardiogenic shock caused by right ventricular infarction, as well as in pregnant women with preeclampsia or eclampsia. These conditions may be worsened by the potent vasoconstrictive effects of norepinephrine, which can lead to decreased tissue perfusion, increased myocardial oxygen demand, and potentially life-threatening arrhythmias 1. In such cases, alternative vasopressor agents like dobutamine, vasopressin, or phenylephrine may be more suitable, depending on the specific clinical context and the patient's individual needs 1. For example, dobutamine may be preferred in patients with compromised systolic function, while vasopressin may be used in patients who are refractory to other vasopressors 1. It is essential to carefully evaluate the patient's condition and tailor the treatment approach to minimize the risk of adverse effects and optimize outcomes. Some key points to consider when using norepinephrine include:

• Avoiding its use in hypovolemic shock until adequate fluid resuscitation has occurred
• Using caution in patients with severe cardiac disease or ventricular tachyarrhythmias
• Avoiding its use in patients with pheochromocytoma or mesenteric/peripheral ischemia
• Considering alternative agents in pregnant women with preeclampsia or eclampsia
• Monitoring closely for signs of decreased tissue perfusion or increased myocardial oxygen demand. Overall, the use of norepinephrine requires careful consideration of the patient's individual needs and clinical context to minimize the risk of adverse effects and optimize outcomes 1.

From the FDA Drug Label

LEVOPHED should not be given to patients who are hypotensive from blood volume deficits except as an emergency measure to maintain coronary and cerebral artery perfusion until blood volume replacement therapy can be completed LEVOPHED should also not be given to patients with mesenteric or peripheral vascular thrombosis (because of the risk of increasing ischemia and extending the area of infarction) The use of LEVOPHED during cyclopropane and halothane anesthesia is generally considered contraindicated because of the risk of producing ventricular tachycardia or fibrillation The same type of cardiac arrhythmias may result from the use of LEVOPHED in patients with profound hypoxia or hypercarbia.

Norepinephrine drip is not useful or even contraindicated in the following situations:

• Hypotension due to blood volume deficits, except in emergency situations to maintain coronary and cerebral artery perfusion until blood volume replacement therapy can be completed 2
• Mesenteric or peripheral vascular thrombosis, unless necessary as a life-saving procedure 2
• Cyclopropane and halothane anesthesia, due to the risk of producing ventricular tachycardia or fibrillation 2
• Profound hypoxia or hypercarbia, due to the risk of cardiac arrhythmias 2

From the Research

Situations where Norepinephrine Drip is Not Useful or Contraindicated

• Norepinephrine drip may not be useful in certain situations, including:
  • Cardiogenic shock: According to 3, norepinephrine use in cardiogenic shock patients is associated with increased 30-day mortality.
  • Hypovolemic shock: As stated in 4, vasopressors, including norepinephrine, are less often used in hypovolemic shock.
• Contraindications for norepinephrine drip include:
  • None explicitly stated in the provided evidence, but potential adverse effects of norepinephrine, such as excessive vasoconstriction, organ ischemia, hyperglycemia, hyperlactatemia, tachycardia, and tachyarrhythmias, should be considered 4.

Alternative Vasopressors

• In situations where norepinephrine is not useful or contraindicated, alternative vasopressors may be considered, such as:
  • Vasopressin: May be added in cases of refractory hypotension 5 or used in patients with right ventricular failure and pulmonary hypertension 6.
  • Epinephrine: May be added in norepinephrine-refractory patients 4 or used as an alternative to norepinephrine in cardiogenic shock 6.
  • Dopamine: Recommended only in bradycardic patients 4, but may be considered in certain cases of cardiogenic shock, although norepinephrine is generally preferred 7.

Important Considerations

• The choice of vasopressor and dose should be individualized based on patient characteristics and physician practice 4.
• Predictive biomarkers may guide vasopressor selection in the future 4.
• Novel vasopressors, such as selepressin, are in development 4.