Noradrenaline (Norepinephrine)

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.