What is the recommended dose of noradrenaline (norepinephrine) for treating significant hypotension?

Recommended Dosing of Norepinephrine for Significant Hypotension

Norepinephrine should be initiated at 0.2-1.0 μg/kg/min intravenously for significant hypotension, with dose titration based on blood pressure response. 1, 2

Initial Dosing

• According to FDA labeling, start with 8-12 μg/min (0.25-0.375 mL/min of standard concentration) and adjust to establish and maintain systolic blood pressure of 80-100 mmHg 3
• The average maintenance dose typically ranges from 2-4 μg/min (0.0625-0.125 mL/min) 3
• For septic shock specifically, the recommended infusion rate is 0.2-1.0 μg/kg/min 2, 1

Administration Guidelines

• Administer through a large vein, preferably with central venous access, to prevent extravasation and tissue necrosis 3
• Continuous arterial blood pressure monitoring is strongly recommended for patients receiving norepinephrine 2
• Titrate to effect rather than using a fixed dose, with the goal of maintaining adequate organ perfusion 2

Clinical Context-Specific Considerations

• In cardiogenic shock: Norepinephrine is advised for persistently hypotensive patients, especially those with tachycardia 2
• In distributive shock (sepsis): Norepinephrine is recommended as the first-line vasopressor after adequate fluid resuscitation 2
• In hypovolemic shock: Ensure adequate fluid resuscitation before or concurrent with norepinephrine administration 2

Titration Strategy

• Target a mean arterial pressure (MAP) of 65 mmHg for most patients 2
• Consider higher MAP targets (75-85 mmHg) in patients with chronic hypertension 2
• Gradually reduce infusion rate when discontinuing to avoid rebound hypotension 3

Monitoring During Administration

• Continuously monitor blood pressure, heart rate, and ECG 2
• Assess tissue perfusion markers including urine output, mental status, skin perfusion, and serum lactate 2
• Watch for potential adverse effects including cardiac arrhythmias, tissue ischemia, and extravasation 3

Alternative Agents When Norepinephrine Is Insufficient

• Epinephrine (0.05-0.5 μg/kg/min) can be added or substituted when additional blood pressure support is needed 2, 1
• Vasopressin (up to 0.03 U/min) can be added to norepinephrine to raise MAP or decrease norepinephrine requirements 2, 1
• Dopamine should be reserved for patients with low risk of tachyarrhythmias or those with bradycardia 2

Cautions and Contraindications

• Avoid abrupt discontinuation as this may cause marked hypotension 3
• Use with caution in patients with coronary artery disease due to potential for increased myocardial oxygen demand 2
• Monitor for cardiac arrhythmias, especially in patients with underlying heart disease 3

Remember that norepinephrine is approximately 13 times more potent than phenylephrine when administered as an infusion for blood pressure control 4, making precise dosing and careful monitoring essential for safe administration.