How to taper and stop noradrenaline (norepinephrine) and vasopressin infusion?

Tapering and Discontinuation of Norepinephrine and Vasopressin Infusions

Norepinephrine and vasopressin infusions should be tapered gradually to avoid rebound hypotension, with norepinephrine reduced by 0.05-0.1 μg/kg/min every 5-15 minutes and vasopressin discontinued only after norepinephrine has been successfully weaned. 1, 2

General Principles for Vasopressor Tapering

• Ensure hemodynamic stability before tapering:

  • Confirm adequate volume status and resolution of underlying cause of shock
  • Maintain stable MAP ≥65 mmHg for at least 2-4 hours
  • Verify improving tissue perfusion markers (lactate clearance, urine output, skin perfusion)

• Monitoring during tapering:

  • Continuous arterial pressure monitoring is essential
  • Monitor for signs of deterioration (tachycardia, decreasing urine output, worsening mental status)
  • Assess tissue perfusion markers regularly

Specific Tapering Protocol

Norepinephrine Tapering

1. Initial reduction: Decrease dose by 0.05-0.1 μg/kg/min
2. Reassessment period: Wait 5-15 minutes to assess hemodynamic response 1
3. Subsequent reductions: Continue reducing by 0.05-0.1 μg/kg/min if MAP remains stable
4. Final stages: Use smaller increments (0.01-0.02 μg/kg/min) when approaching discontinuation
5. Avoid abrupt withdrawal: The FDA label explicitly warns against sudden cessation as it may result in marked hypotension 2

Vasopressin Tapering

1. Sequence: Only begin vasopressin tapering after norepinephrine has been reduced to minimal doses or completely discontinued 1
2. Fixed-dose approach: Since vasopressin is typically administered at a fixed dose (0.03 U/min), it can often be discontinued without tapering once norepinephrine has been successfully weaned 1
3. Alternative approach: If concerned about rebound effects, consider reducing to 0.015 U/min for 1-2 hours before discontinuation

Special Considerations

• Rebound risk: Monitor closely for hypotension for at least 30-60 minutes after complete discontinuation of vasopressors
• Central line removal: Do not remove central venous access immediately after vasopressor discontinuation; wait at least 1-2 hours to ensure hemodynamic stability
• Extravasation risk: If peripheral administration was used (though central access is strongly preferred), inspect the site carefully during and after discontinuation 3

Potential Complications and Management

• Rebound hypotension: If significant hypotension occurs during tapering:

  • Return to previous stable dose
  • Reassess volume status and consider additional fluid bolus if appropriate
  • Rule out new or worsening sources of shock
  • Attempt tapering again with smaller increments and longer intervals

• Tachyarrhythmias: May occur during tapering due to sympathetic compensation

  • Monitor cardiac rhythm continuously
  • Consider slower tapering if significant tachycardia develops

Evidence Summary

The recommended tapering approach is based on clinical guidelines that emphasize gradual reduction of vasopressors to prevent adverse hemodynamic effects. The FDA label for norepinephrine explicitly states "When discontinuing the infusion, reduce the flow rate gradually. Avoid abrupt withdrawal" 2. While there are no randomized controlled trials specifically addressing optimal tapering protocols, clinical experience and physiological principles support this approach.

The Vasopressor Management in Shock guidelines recommend titrating norepinephrine by 0.05-0.1 μg/kg/min every 5-15 minutes to maintain target MAP, which can be applied in reverse for tapering 1. These guidelines also suggest that vasopressin should be considered as a second-line agent and typically discontinued after norepinephrine has been successfully weaned.