What is the dosage and administration of noradrenaline (norepinephrine) tartarate for treating hypotension and septic shock?

Noradrenaline (Norepinephrine) Tartrate Dosage and Administration for Hypotension and Septic Shock

Norepinephrine tartrate should be administered with an initial dose of 0.25-0.375 mL/min (8-12 mcg/min of base) for hypotension and septic shock, with titration to maintain a target mean arterial pressure (MAP) of 65 mmHg. 1, 2

Initial Vasopressor Selection

• Norepinephrine is the first-choice vasopressor for treating hypotension in septic shock due to its superior efficacy and safety profile 2, 3
• Administration requires central venous access, though peripheral administration may be considered in emergent situations when central access is not immediately available 3, 4
• All patients requiring vasopressors should have an arterial catheter placed as soon as practical for continuous blood pressure monitoring 2, 3

Dosing Protocol

• Initial dose: 0.25-0.375 mL/min (8-12 mcg/min of base) 1
• Target: Establish and maintain a MAP of 65 mmHg (systolic BP usually 80-100 mmHg) 2, 1
• Average maintenance dose: 0.0625-0.125 mL/min (2-4 mcg/min of base) 1
• Titration: Adjust rate to achieve target blood pressure sufficient to maintain vital organ perfusion 1, 5
• Higher MAP targets (>65 mmHg) may be considered in patients with chronic hypertension 5

Administration Considerations

• Norepinephrine should be administered via a central venous catheter whenever possible to minimize risk of extravasation 3, 1
• Continuous arterial blood pressure monitoring is essential for patients receiving norepinephrine 3
• Early administration of norepinephrine (simultaneously with fluid resuscitation) may be beneficial in profound hypotension to rapidly restore organ perfusion 6, 7
• Avoid sudden discontinuation of infusion as this may result in marked hypotension; reduce infusion rate gradually 1

Management of Refractory Hypotension

• If target MAP cannot be achieved with maximum doses of norepinephrine, consider adding vasopressin (0.03 units/minute) to either raise MAP or decrease norepinephrine dosage 2, 3
• Vasopressin doses higher than 0.03-0.04 units/minute should be reserved for salvage therapy when other vasopressors have failed 3
• Epinephrine can be added to or potentially substituted for norepinephrine when an additional agent is needed 2
• Dopamine should only be used as an alternative to norepinephrine in highly selected patients with low risk of tachyarrhythmias or relative bradycardia 2, 3

Monitoring and Adverse Effects

• Monitor for potential adverse effects including ischemic injury, bradycardia, anxiety, headache, respiratory difficulty, and extravasation necrosis at injection site 1
• Cardiac function should be closely monitored in patients with underlying heart disease due to risk of arrhythmias 1
• If extravasation occurs, infiltrate the area as soon as possible with 10-15 mL of saline solution containing 5-10 mg of an adrenergic blocking agent to prevent local necrosis 1

Important Considerations

• Adequate fluid resuscitation should precede or accompany vasopressor therapy in septic shock 2, 6
• Low-dose dopamine should not be used for renal protection 2, 3
• Phenylephrine is not recommended except in specific circumstances such as when norepinephrine causes serious arrhythmias 2
• Early administration of norepinephrine may help reduce total fluid requirements and potentially improve outcomes 6, 7