How to Taper Noradrenaline
Taper norepinephrine gradually by decreasing the infusion rate in small increments (typically 0.01-0.02 mcg/kg/min or 1-2 mcg/min absolute dose) every 15-30 minutes while continuously monitoring mean arterial pressure (MAP) to ensure it remains ≥65 mmHg.
Tapering Strategy
The available guidelines do not provide explicit protocols for norepinephrine tapering, but the principles can be derived from dosing recommendations and hemodynamic monitoring guidance:
Initial Assessment Before Tapering
Before initiating any taper, confirm:
- MAP has been stable ≥65 mmHg for at least 30 minutes 1
- Patient shows adequate tissue perfusion (improving lactate, adequate urine output, normal mental status)
- Underlying cause of shock is resolving
- Adequate intravascular volume status has been maintained 1
Tapering Protocol
Decrease the norepinephrine dose incrementally:
- Reduce by 0.01-0.02 mcg/kg/min (weight-based) or 1-2 mcg/min (absolute dose) every 15-30 minutes 2, 3
- Monitor MAP continuously with arterial line monitoring 1
- If MAP drops below 65 mmHg, pause the taper and reassess volume status
- Resume taper only after MAP stabilizes ≥65 mmHg for another 30 minutes
Monitoring During Taper
Continuous arterial blood pressure monitoring is essential 1. The 2016 Surviving Sepsis Campaign guidelines suggest that all patients requiring vasopressors should have an arterial catheter placed as soon as practical 1.
Set appropriate MAP alarms: Configure monitor alarms to match your target MAP range (e.g., 65-75 mmHg). Evidence shows that adjusted MAP alarms dramatically improve time spent within target range compared to default systolic pressure alarms 4.
Common Pitfalls to Avoid
- Tapering too rapidly: Abrupt decreases can cause precipitous MAP drops and organ hypoperfusion
- Inadequate volume assessment: Always reassess fluid status if MAP falls during taper—occult hypovolemia is common 2
- Ignoring adjunct vasopressors: If patient is on vasopressin (up to 0.03 U/min) or epinephrine in addition to norepinephrine, consider tapering norepinephrine first while maintaining adjunct agents 1
- Pump changeover errors: Use smart infusion pumps with automatic changeover capability when available to prevent hemodynamic instability during syringe changes 5
Special Considerations
For patients with chronic hypertension: A higher MAP target may be appropriate during the taper (e.g., 70-80 mmHg), as these patients may require higher perfusion pressures 6.
Weight-based vs. non-weight-based dosing: Recent evidence suggests weight-based dosing may lead to lower total norepinephrine requirements while achieving similar MAP targets 3. However, both approaches are acceptable for tapering.
When to Stop the Taper
Pause or reverse the taper if:
- MAP drops below 65 mmHg
- Signs of inadequate perfusion emerge (rising lactate, decreased urine output, altered mental status)
- Patient develops new arrhythmias
Final Discontinuation
Once norepinephrine reaches very low doses (typically <0.02 mcg/kg/min or <2 mcg/min), observe the patient for 30-60 minutes at this minimal dose before complete discontinuation to ensure hemodynamic stability persists 2.