Vasopressor (Alpha-1 and Beta-1 Agonist) Pregnancy: Because of its indications, noradrenaline may be administered if necessary during pregnancy; however the pharmacodynamic properties must be considered - it may impair placental perfusion and induce fetal bradycardia, and may exert a contractile effect on the pregnant uterus and lead to fetal asphyxia in late pregnancy. Breast-feeding: no information is available on the use of noradrenaline in breast-feeding.

Noradrenaline (Norepinephrine)

Brand names: Noradrenaline acid tartrate (generic)

Used in: Sepsis

Noradrenaline (norepinephrine) is a potent intravenous vasopressor used as the first-line agent to restore blood pressure in septic and other vasodilatory shock states in critical care.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: Initial dose of noradrenaline base is usually between 0.05-0.15 micrograms/kg/min; the recommended maintenance range of noradrenaline base is between 0.05-1.5 micrograms/kg/min

Route: Intravenous infusion only, administered via a central venous catheter to minimise the risk of extravasation and subsequent tissue necrosis, using an infusion pump or a syringe pump. Administration via a peripheral cannula and/or peripheral vein is CONTRAINDICATED.

Frequency: Continuous infusion at a controlled rate, titrated in steps of 0.05-0.1 micrograms/kg/min of noradrenaline base according to the pressor effect observed

Max: The upper end of the recommended maintenance range is 1.5 micrograms/kg/min of noradrenaline base; no absolute maximum dose is stated in §4.2

UNITS ARE MICROGRAMS PER KG PER MINUTE OF NORADRENALINE BASE. The fetched SPC is the 0.08 mg/ml ready-to-use solution for infusion (https://www.medicines.org.uk/emc/product/8776/smpc): it should NOT be diluted before use and should not be mixed with other medicines. Blood pressure should be monitored carefully for the duration of therapy, preferably by arterial blood pressure monitoring, and the patient monitored carefully throughout. There is great individual variation in the dose required to attain and maintain normotension; the aim should be to establish a low normal systolic blood pressure (100-120 mmHg) or an adequate mean arterial blood pressure (greater than 65 mmHg, depending on the patient's condition). Manual bolus for priming when initiating an infusion is NOT recommended. Caution is required during infusion relay to avoid haemodynamic instability; continuous infusion through a double pump system and an extension set reducing dead-space volume should be encouraged. DURATION: treatment should be continued until high-dose vasoactive drug support is no longer indicated, at which point the infusion should be gradually decreased then switched to an infusion of lower concentration - abrupt withdrawal can result in acute hypotension. The SPC provides a weight-versus-rate table for the 0.08 mg/ml presentation (for example, at 70 kg: 0.05 micrograms/kg/min = 0.21 mg/h = 2.6 ml/h; 0.5 micrograms/kg/min = 2.1 mg/h = 26.3 ml/h; 1.5 micrograms/kg/min = 6.3 mg/h = 78.8 ml/h) - these ml/h rates apply ONLY to the 0.08 mg/ml concentration and must be recalculated for any other concentration. PAEDIATRIC: noradrenaline is indicated for adults only; efficacy and safety in children and adolescents have not been established. The US label (openFDA, norepinephrine bitartrate) uses different units and a different presentation (initial 8 to 12 micrograms per minute, typical maintenance 2 to 4 micrograms per minute, after dilution of 4 mg in 1,000 ml of 5% dextrose to give 4 micrograms/ml) - do not mix the UK per-kg-per-minute regimen with the US flat micrograms-per-minute regimen.

Dose adjustments

Renal

There is no experience of treatment in patients with renal or hepatic impairment.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Hypersensitivity to the active substance or to any of the excipients
Do not use with cyclopropane and halothane anaesthetics as this may cause serious cardiac arrhythmias including ventricular fibrillation
Administration via peripheral cannula and/or peripheral vein

Side effects

Cardiac - tachycardia, bradycardia (probably as a reflex result of blood pressure rising), arrhythmias, palpitations, increased cardiac contractility, acute cardiac insufficiency, stress cardiomyopathy
Vascular - arterial hypertension and tissue hypoxia; ischaemic injury due to potent vasoconstrictor action (coldness and paleness of the skin, peripheries and face), gangrene of the extremities, cyanosis
Administration site - possibility of irritation and necrosis at the injection site
Nervous system and psychiatric - headache, tremor, anxiety
Respiratory - respiratory insufficiency or difficulty, dyspnoea
Eye - acute glaucoma (very frequent in patients anatomically predisposed with closing of the iridocorneal angle); also vomiting and urinary retention. In hypersensitivity or overdose, hypertension, photophobia, retrosternal pain, pharyngeal pain, pallor, intense sweating and vomiting may appear more frequently.

Interactions

Cyclopropane and halothane anaesthetics - contraindicated; may cause serious cardiac arrhythmias including ventricular fibrillation (UK SPC §4.3)
Monoamine oxidase inhibitors or other drugs with MAO-inhibiting properties (e.g. linezolid) - can cause severe, prolonged hypertension; monitor for hypertension if use cannot be avoided (US label §7.1)
Tricyclic antidepressants (amitriptyline, nortriptyline, protriptyline, clomipramine, desipramine, imipramine) - can cause severe, prolonged hypertension; monitor if use cannot be avoided (US label §7.2)
Antidiabetic drugs - noradrenaline can decrease insulin sensitivity and raise blood glucose; monitor glucose and consider dosage adjustment (US label §7.3)
Halogenated anaesthetics (cyclopropane, desflurane, enflurane, isoflurane, sevoflurane) - increase cardiac autonomic irritability; the US §7.4 text is truncated at the source-fetch limit (US label §7.4)
Interactions other than the contraindicated anaesthetics are taken from the US prescribing information because the fetched eMC bundle contains no §4.5 section - verify against the full UK SPC §4.5

Clinical monograph

How it works

It is a predominantly alpha-1 adrenergic agonist causing intense peripheral vasoconstriction and a rise in systemic vascular resistance, with modest beta-1 activity providing some inotropic support, thereby raising mean arterial pressure.

Prescribing in practice

Extravasation causes severe local vasoconstriction and tissue necrosis, so it should be given through a central venous catheter (or a closely monitored large peripheral line as a temporising measure) via an infusion pump.
Excessive vasoconstriction can compromise perfusion of the limbs, gut and kidneys and cause reflex bradycardia, so titrate to a defined mean arterial pressure target.
It must never be given as a bolus; abrupt rate changes cause swings in blood pressure, so adjust gradually against continuous arterial monitoring.

Monitoring

Monitor continuous invasive arterial blood pressure, heart rate, peripheral and end-organ perfusion and the infusion site for extravasation.

Counselling the patient

This is a powerful blood-pressure-supporting drip used in intensive care, usually given through a central line.
Staff watch the drip site carefully because leakage outside the vein can damage tissue.
The dose is adjusted continuously to keep blood pressure at a safe target.

Evidence & guidelines

Noradrenaline is the recommended first-line vasopressor in septic shock under the Surviving Sepsis Campaign guidelines.

Reference: Surviving Sepsis Campaign 2021; SOAP II Trial (De Backer et al, NEJM 2010); 65-TRIAL (Lamontagne et al, NEJM 2020); Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways