norepinephrine

Disclaimer to the Online Edition

This Manual has been designed for use in the NICU at London Health Sciences Centre (LHSC), London, Ontario, Canada, and represents clinical practice at this institution. The information contained within the Manual may not be applicable to other centres. If users of this Manual are not familiar with a drug, it is recommended that the official monograph be consulted before it is prescribed and administered. Any user of this information is advised that the contributors, Editor and LHSC are not responsible for any errors or omissions, and / or any consequences arising from the use of the information in this Manual.

norepinephrine

Indication

  • Treatment of severe hypotension after adequate fluid volume replacement, warm shock and/or vasodilatory shock
  • Mainly stimulates alpha-adrenergic receptors causing, vasoconstriction

Dosage Guidelines

  • Initial dose: 0.05-0.15 microgram/kg/min IV continuous infusion.  Titrate to desired blood pressure as per MD/NP order every 15 to 30 minutes
  • Maximum dose: 0.2 microgram/kg/min. Escalation beyond this dose would need echocardiographic guidance/MRP order

Administration

  • IV continuous infusion

  • For patients 1 kg or less:

    Use norepinephrine 8 microgram/mL

    To make 50 mL of norepinephrine [8 microgram/mL] [0.4 mg/50mL]:

    Add 0.4 mL (0.4 mg) of norepinephrine [1 mg/mL] to 49.6 mL of solution

  • For patients over 1 kg to 3 kg:

    Use norepinephrine 16 microgram/mL

    To make 50 mL of norepinephrine [16 microgram/mL] [0.8 mg/50 mL]:

    Add 0.8 mL (0.8 mg) of norepinephrine [1 mg/mL] to 49.2 mL of solution

  • For patients over 3 kg:

    Use norepinephrine 32 microgram/mL

    To make 50 mL of norepinephrine [32 microgram/mL] [1.6 mg/50 mL]:

    Add 1.6 mL (1.6 mg) of norepinephrine [1 mg/mL] to 48.4 mL of solution

  • Administer via central line whenever possible

Adverse Effects

  • Cardiac arrythmias, bradycardia, peripheral (digital) ischemia
  • Skin necrosis with extravasation

Comments

  • Hypovolemia should be corrected prior to use
  • Alpha effects (vasoconstriction) are significantly greater than beta effects (inotropic and chronotropic effects) which are mild.
  • If ventricular contractility is impaired caution should be exercised as excessive vasoconstriction will result in increased afterload.
  • Norepinephrine may cause pulmonary vasodilatation particularly in neonates with preexisting increase in basal pulmonary vascular tone.
  • Monitor blood pressure, heart rate, ECG, urine output, peripheral perfusion
  • Monitor IV site routinely for extravasation
  • If extravasation occurs, consider the use of phentolamine 
  • Protect from light

Supplied As

  • 1 mg/mL, 4 mL vial
  • Supplied by Pharmacy as standard concentrations:
    • 1 kg or less: 8 mcg/mL, supplied as 0.4 mg in 50 mL IV solution
    • Over 1 kg to 3 kg: 16 mcg/mL, supplied as 0.8 mg in 50 mL IV solution 
    • Over 3 kg: 32 mcg/mL, supplied as 1.6 mg in 50 mL IV solution
  • At LHSC, standard concentration reference charts are available on the NICU Intranet site

References

Lexi Sick Kids and Lexi Pediatric and Neonatal