norepinephrine

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