From the Guidelines
Norepinephrine infusion is recommended as the first-line vasopressor for patients with severe hypotension, particularly in septic shock, cardiogenic shock, or other vasodilatory shock states, when fluid resuscitation alone is insufficient to maintain adequate blood pressure. The typical starting dose is 0.01-0.03 mcg/kg/minute, administered through a central venous catheter, and titrated every 3-5 minutes to achieve a target mean arterial pressure (MAP) of 65 mmHg, as recommended by the Surviving Sepsis Campaign guidelines 1.
Key Considerations
- Norepinephrine should be prepared as 4-16 mg in 250-500 mL of D5W or normal saline (typically 8 mg/250 mL, yielding 32 mcg/mL) 1.
- Blood pressure and heart rate must be continuously monitored during administration, with frequent assessment of peripheral perfusion, urine output, and mental status.
- Norepinephrine works primarily as an alpha-1 adrenergic agonist, causing peripheral vasoconstriction to increase blood pressure, with some beta-1 activity that provides mild inotropic support.
- Abrupt discontinuation should be avoided; instead, the infusion should be gradually weaned as the patient's condition improves.
- Extravasation can cause severe tissue necrosis, so infusion site monitoring is essential.
Additional Recommendations
- Vasopressin, 0.03 units/minute, can be added to norepinephrine with the intent of either raising MAP or decreasing norepinephrine dosage 1.
- Epinephrine can be added to and potentially substituted for norepinephrine when an additional agent is needed to maintain adequate blood pressure 1.
- Dopamine can be used as an alternative vasopressor agent to norepinephrine only in highly selected patients (e.g., patients with low risk of tachyarrhythmias and absolute or relative bradycardia) 1.
Recent Guidelines
A recent study published in Intensive Care Medicine in 2018 provides a global perspective on vasoactive agents in shock, supporting the use of norepinephrine as the initial vasoactive drug after appropriate fluid resuscitation in distributive shock 1.
Patient-Specific Considerations
The target MAP should be individualized based on the patient's condition, with a strong recommendation favoring an initial MAP target of 65 mmHg over higher MAP targets, as suggested by the Surviving Sepsis Campaign guidelines 1.
From the Research
Norepinephrine Infusion in Severe Hypotension
- Norepinephrine is the first-line agent recommended for the treatment of septic shock to correct hypotension due to depressed vascular tone 2.
- The optimal dosage of norepinephrine infusion is not explicitly stated, but the goal is to achieve a mean arterial pressure (MAP) of at least 65 mmHg, with higher values targeted in cases of chronic hypertension 2.
- Early administration of norepinephrine is beneficial in septic shock patients to restore organ perfusion, and the MAP target should be individualized 2.
Comparison with Other Vasopressors
- Norepinephrine is superior to other vasopressors in minimizing the occurrence of arrhythmia, making it a safe choice for use in septic shock 3.
- There is no significant difference in the number of participants who achieved the target MAP, time to achieve the target MAP, and all-cause 28-day mortality between norepinephrine and other vasopressors 3.
- Vasopressin may be added to norepinephrine to raise MAP or decrease norepinephrine dosage, and early initiation of vasopressin may achieve and maintain goal MAP sooner and resolve organ dysfunction more effectively 4, 5.
Clinical Considerations
- The choice of vasopressor and dosage should be individualized based on the patient's condition and response to treatment 2, 3.
- The use of norepinephrine and vasopressin in combination may be beneficial in certain cases, but further investigation is needed to determine the optimal approach 6.
- The efficacy and safety of norepinephrine infusion in severe hypotension should be carefully monitored, and adjustments made as necessary to achieve the desired clinical outcomes 2, 3, 4, 6, 5.