What is the role of peripheral norepinephrine (noradrenaline)?

From the Guidelines

Norepinephrine is the first-choice vasopressor for treating severe hypotension and shock, particularly in septic shock and neurogenic shock, as recommended by the Surviving Sepsis Campaign guidelines 1. The typical starting dose is 0.1-0.5 mcg/kg/min administered through a central venous catheter, with titration based on blood pressure response up to 30 mcg/min if needed. This medication works by stimulating alpha-1 adrenergic receptors in blood vessels, causing vasoconstriction and increasing blood pressure. It also has some beta-1 adrenergic effects that increase cardiac contractility and heart rate. Some key points to consider when using norepinephrine include:

• Administration via a central line due to the risk of extravasation and tissue necrosis if given through peripheral IVs 1.
• Continuous blood pressure monitoring is essential, along with frequent assessment of peripheral perfusion and urine output.
• Common side effects include hypertension, bradycardia, arrhythmias, and decreased peripheral perfusion 1.
• The medication should be tapered slowly rather than abruptly discontinued to prevent rebound hypotension.
• Norepinephrine is particularly useful in septic shock and neurogenic shock when fluid resuscitation alone is insufficient to maintain adequate tissue perfusion 1. It's worth noting that while other vasopressors like vasopressin and epinephrine can be used in certain situations, norepinephrine remains the first-line choice due to its efficacy and safety profile, as supported by the most recent and highest quality evidence 1.

From the Research

Peripheral Norepinephrine Administration

• Peripheral norepinephrine administration has been studied as a potential alternative to central venous catheter (CVC) administration, with the goal of reducing the risk of central line complications 2, 3.
• Studies have shown that peripheral administration of norepinephrine can be safe and effective, with a low risk of tissue ischemia and extravasation events 2, 3.
• A protocol for peripheral norepinephrine administration was developed and implemented in one study, which found that 34% of patients did not require a CVC and 97% of infusions ran for less than 24 hours 2.
• Another study found that implementing a protocol for peripheral administration of norepinephrine safely avoided 1 CVC day in the average patient, with 51.6% of patients not requiring CVC insertion 3.

Norepinephrine in Sepsis

• Norepinephrine is considered the first-line vasopressor for patients with sepsis-associated hypotension 4, 5.
• The optimal adjuvant vasopressor to norepinephrine in septic shock remains controversial, with some studies suggesting that vasopressin or epinephrine may be effective alternatives 6, 5.
• Experts' recommendations currently position norepinephrine as the first-line vasopressor in septic shock, with vasopressin and its analogues as second-line options 5.
• The dose and duration of norepinephrine administration may vary depending on the individual patient's response and the severity of their condition 5.

Safety and Efficacy

• The safety and efficacy of peripheral norepinephrine administration have been evaluated in several studies, with results suggesting that it can be a safe and effective alternative to CVC administration 2, 3.
• The risk of extravasation events and tissue ischemia is low, and most extravasations cause no or minimal tissue injury 3.
• Nursing adherence to protocol elements, such as gauge, site, and blood return, is important for ensuring the safe and effective administration of peripheral norepinephrine 2.