What are the contraindications for norepinephrine (noradrenaline)?

Contraindications for Norepinephrine

Norepinephrine is absolutely contraindicated in patients who are hypotensive from blood volume deficits (except as a temporary emergency measure to maintain coronary and cerebral perfusion until volume replacement is completed), and in patients with mesenteric or peripheral vascular thrombosis due to risk of extending ischemia and infarction. 1

Absolute Contraindications

Hypovolemic Hypotension

• Norepinephrine should not be given to patients with hypotension from blood volume deficits except as an emergency measure to maintain coronary and cerebral artery perfusion until blood volume replacement therapy can be completed. 1
• If norepinephrine is continuously administered to maintain blood pressure without correcting volume depletion, severe complications occur including: severe peripheral and visceral vasoconstriction, decreased renal perfusion and urine output, poor systemic blood flow despite "normal" blood pressure, tissue hypoxia, and lactate acidosis. 1
• Volume depletion must always be corrected before or concurrently with norepinephrine administration. 2

Mesenteric or Peripheral Vascular Thrombosis

• Norepinephrine is contraindicated in patients with mesenteric or peripheral vascular thrombosis because of the risk of increasing ischemia and extending the area of infarction. 1
• The only exception is when the attending physician determines norepinephrine administration is necessary as a life-saving procedure. 1

Specific Anesthetic Agents

• Use during cyclopropane and halothane anesthesia is generally contraindicated because these agents increase cardiac autonomic irritability and sensitize the myocardium to norepinephrine, creating risk of ventricular tachycardia or fibrillation. 1

Severe Hypoxia or Hypercarbia

• Norepinephrine is contraindicated in patients with profound hypoxia or hypercarbia due to risk of producing cardiac arrhythmias (ventricular tachycardia or fibrillation). 1

Relative Contraindications and Cautions

Cardiogenic Shock

• In cardiogenic shock, norepinephrine should be used with extreme caution and only transiently, as it increases left ventricular afterload which can further decrease cardiac output and end-organ blood flow. 2
• It should only be used when combination of inotropic agents and fluid challenge fails to restore adequate arterial and organ perfusion. 2

Ischemic Heart Disease

• Use cautiously in patients with ischemic heart disease as norepinephrine may increase myocardial oxygen requirements and consumption. 2

Drug Interactions

• Concurrent use with phosphodiesterase inhibitors may cause severe hypotension. 2
• Norepinephrine has additive effects when combined with other vasopressors. 2

Important Clinical Pitfalls

A common error is using norepinephrine to maintain blood pressure in inadequately volume-resuscitated patients. This creates a dangerous situation where blood pressure appears adequate but tissue perfusion remains severely compromised, leading to multi-organ dysfunction. 1 Always ensure adequate intravascular volume status before initiating or continuing norepinephrine therapy.

The risk of tachyarrhythmias exists even at low doses in susceptible patients, though this is uncommon. 3 Peripheral administration carries risk of tissue necrosis if extravasation occurs, though recent evidence suggests this can be managed safely with appropriate protocols and monitoring. 4, 5