Norepinephrine is an adrenergic agent used to treat hypotension and shock. It works by stimulating alpha-1 receptors to cause vasoconstriction and increase blood pressure. While it can be used for many types of shock, it is most important to ensure adequate fluid resuscitation first before administering norepinephrine. Special care must be taken to avoid infiltration which can cause tissue damage.

1. Norepinephrine
Nick Rathert, MD
For the
REMO Medical Advisory Committee

2. Norepinephrine (Levophed®)
• Classification: Adrenergic agent
• Onset: Rapid (1-2 minutes max)
• Duration of action: Short (1-2 minutes)

3. Background
• Previously viewed as one of many options for
hypotension
– Pressor of choice for essentially all hypotension
– Surviving Sepsis treatment of choice

4. Adrenergic Mechanism
• Beta 1 – stimulates cardiac rate and
contractility
• Alpha 1 – stimulates peripheral
vasoconstriction
• Beta 2 – no effect on airway smooth muscle

5. Goals of Care
• Reversal of shock state
– A state of tissue hypoperfusion
• Increase perfusion to end organs via increased
systemic vascular resistance
• Good initial BLS is paramount – recognition
• Good ALS is key – fluid resuscitation
• Don’t squeeze the pipes until the tank is full!

6. Indications?
Nearly Any Shock State!!
ROSC
Neurogenic
Cardiogenic/LVAD
Anaphylactic
Septic
BUT – Correct Volume First

7. Contraindications
• There are no clear contraindications for
norepinephrine in EMS
• Relative contraindication would be depleted
intravascular volume
– Patient must receive appropriate fluid
resuscitation first

8. Cautions
• Remember to “fill the tank” before you add a
pressor
• Must ensure and reevaluate access
– Infiltration can lead to severe tissue necrosis
– If infiltration is suspected, stop drip immediately
and notify hospital staff upon arrival

9. Specific information
• No pre-mix available
• Hospital concentrations will vary
• Supplied: 1mg/ml in 4 ml vial
• Dosing: Continuous Infusion
• Pregnancy category C

10. Administration
• Supplied as 4 mg in 4 ml
• Mix into NS 1,000 ml
• 4 mg in 1000ml = 4 mcg/ml
• Dosing? Start at 2 mcg/min or 0.5 to 5
ml/minute
– Titrate to a maximum of 20 mcg/min MAP >65

11. Protocol

12. Protocols

13. Thanks.