What if a norepinephrine (noradrenaline) infusion gets flushed?

Management of Inadvertent Norepinephrine Infusion Bolus

If a norepinephrine (noradrenaline) infusion gets accidentally flushed into a patient, immediate intervention is required to manage the resulting acute hypertensive crisis and potential cardiovascular complications.

Immediate Actions

• Stop any ongoing norepinephrine infusion immediately 1
• Maintain intravenous access to allow for administration of treatment medications 1
• Assess ABCs (Airway, Breathing, Circulation) and the patient's level of consciousness 1
• Position the patient appropriately - if hypotensive in Trendelenburg position, if respiratory distress sitting up 1
• Monitor vital signs continuously, with special attention to blood pressure and heart rate 1

Management of Cardiovascular Effects

• For severe hypertension:

  • Consider short-acting vasodilators such as sodium nitroprusside to decrease vascular resistance (afterload) 1
  • Monitor blood pressure every minute until stabilized 1

• For bradycardia:

  • Administer atropine 600 μg IV if clinically significant 1

• For rebound hypotension (which may follow the initial hypertensive phase):

  • Administer fluid resuscitation with normal saline 1-2 L IV at a rate of 5-10 mL/kg in the first 5 minutes 1
  • If hypotension persists despite fluid resuscitation, consider vasopressors:
    • Dopamine 400 mg in 500 mL, at a rate 2-20 μg/kg/min 1
    • Vasopressin 25 U in 250 mL of 5% dextrose water or normal saline (0.1 U/mL), dose of 0.01–0.04 U/min 1

• For patients on beta-blockers who develop cardiovascular complications:

  • Administer glucagon 1-5 mg IV infusion over 5 minutes 1

Monitoring and Supportive Care

• Administer oxygen if needed, particularly in patients with pre-existing hypoxemia or myocardial dysfunction 1
• Monitor cardiac rhythm continuously for arrhythmias 1
• Consider corticosteroids (methylprednisolone 1-2 mg/kg IV every 6 hours) to prevent potential inflammatory responses 1
• Continue close observation for at least 24 hours after a severe reaction 1

Special Considerations

• The effects of an inadvertent norepinephrine bolus can be particularly dangerous in patients with:

  • Pre-existing cardiovascular disease
  • Hypertension
  • Cerebrovascular disease
  • Patients on beta-blockers (may have more severe reactions) 1

• Document the incident thoroughly, including:

  • Estimated amount of norepinephrine accidentally administered
  • Patient's vital sign responses
  • Interventions performed
  • Patient's response to treatment 1

Potential Complications to Monitor

• Cardiac arrhythmias
• Myocardial ischemia or infarction
• Pulmonary edema
• Cerebrovascular events
• Organ hypoperfusion during rebound hypotension phase 1

Prevention Strategies

• Use dedicated infusion lines for vasopressors
• Clearly label all vasopressor lines
• Implement safety protocols for vasopressor administration
• Consider using smart pumps with safety features 1

Remember that the effects of a norepinephrine bolus can be rapid and severe, requiring immediate recognition and management to prevent serious cardiovascular complications.