Vasopressor / Cardiogenic Shock Pregnancy: Because of its indications, noradrenaline may be administered if necessary during pregnancy, but its pharmacodynamic properties must be considered: it may impair placental perfusion and induce foetal bradycardia, and may exert a contractile effect on the pregnant uterus and lead to foetal asphyxia in late pregnancy. No information is available on use during breast-feeding.

Noradrenaline (Cardiogenic Shock / Vasopressor)

Brand names: Noradrenaline (Levophed)

Used in: Sepsis

Intravenous noradrenaline (norepinephrine) is a potent endogenous catecholamine used as a first-line vasopressor to restore mean arterial pressure in vasodilatory and cardiogenic shock, given by continuous infusion in a critical-care setting.

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 usually 0.05-0.15 micrograms/kg/min. Recommended maintenance range of noradrenaline BASE 0.05-1.5 micrograms/kg/min.

Route: Intravenous use only - administer as a continuous intravenous infusion via a CENTRAL venous catheter only, to minimise the risk of extravasation and subsequent tissue necrosis. Administration via a peripheral cannula and/or peripheral vein is CONTRAINDICATED. Supplied ready to use: must NOT be diluted before use and must not be mixed with other medicines.

Frequency: Continuous infusion at a controlled rate using an infusion pump or syringe pump; once established, titrate in steps of 0.05-0.1 micrograms/kg/min of noradrenaline base according to the pressor effect observed

Max: The recommended maintenance range extends to 1.5 micrograms/kg/min of noradrenaline base; the SPC states no absolute maximum

UNITS: all doses above are micrograms/kg/MINUTE and are expressed as noradrenaline BASE - confirm whether the local product is labelled as base or as the bitartrate salt before calculating. MONITORING: blood pressure should be monitored carefully for the duration of therapy, preferably by arterial blood pressure monitoring. There is great individual variation in the dose required; the aim is a low normal systolic blood pressure (100-120 mmHg) or an adequate mean arterial pressure (greater than 65 mmHg, depending on the patient's condition). A 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 with an extension set reducing dead-space volume should be encouraged. DURATION: continue until high-dose vasoactive drug support is no longer indicated, then decrease the infusion gradually and switch to an infusion of lower concentration - abrupt withdrawal can result in acute hypotension. The SPC includes a weight-band table (50-100 kg) converting micrograms/kg/min of noradrenaline base to mg/h and to mL/h specifically for this 0.08 mg/mL presentation. EXTRAVASATION: check the infusion site frequently for free flow; if blanching occurs consider changing the site. For ischaemia due to extravasation, stop the infusion and infiltrate the area as quickly as possible with 10 to 15 mL of physiological salt solution containing 5 to 10 mg of phentolamine mesilate, using a fine needle, injected locally throughout the affected (cold, hard, pallid) area - most effective if given within 12 hours. RENAL/HEPATIC: there is no experience of treatment in patients with renal or hepatic impairment. PAEDIATRIC: noradrenaline is indicated for ADULTS ONLY - efficacy and safety of this 50 mL ready-to-use solution for infusion in children and adolescents has not been established; no paediatric dose is stated, refer to a children's formulary and specialist critical care guidance. SOURCE SCOPE: UK SPC for 'Noradrenaline (Norepinephrine) 0.08 mg/ml, solution for infusion'. The bundle also contains a US label for a DIFFERENT presentation (a concentrate requiring dilution, with a non-weight-based rate regimen and different route instructions); that regimen is not applicable to this ready-to-use product and its figures have been deliberately excluded to avoid mixing two incompatible concentration and route schemes.

Dose adjustments

Renal

There is no experience of treatment in patients with renal or hepatic impairment (no dose adjustment is stated).

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
Section 4.4 warning: contraindicated in hypotensive patients in whom circulatory collapse is associated with hypovolaemia, except as an emergency measure to maintain supply to the coronary and cerebral arteries until blood volume replacement therapy can be instituted

Side effects

Vascular: arterial hypertension and tissue hypoxia; ischaemic injury from potent vasoconstriction (coldness and pallor of skin, extremities and face), gangrene of the extremities, cyanosis
Cardiac: tachycardia, bradycardia (probably a reflex result of rising blood pressure), arrhythmias, palpitations, increased myocardial contractility, acute cardiac insufficiency, stress cardiomyopathy
Administration site: possibility of irritation and necrosis at the injection site (extravasation)
Nervous system / psychiatric: headache, tremor, anxiety
Respiratory: respiratory insufficiency or difficulty, dyspnoea; gastrointestinal: vomiting; renal: retention of urine
Eye: acute glaucoma (very frequent in patients anatomically predisposed with closure of the iridocorneal angle)

Interactions

Cyclopropane and halothane anaesthetics - contraindicated; may cause serious cardiac arrhythmias including ventricular fibrillation (UK SPC section 4.3)
Monoamine oxidase inhibitors and other drugs with MAO-inhibiting properties (e.g. linezolid) - can cause severe, prolonged hypertension; monitor for hypertension (US labelling; UK SPC section 4.5 was not retrieved)
Tricyclic antidepressants (amitriptyline, nortriptyline, protriptyline, clomipramine, desipramine, imipramine) - can cause severe, prolonged hypertension (US labelling)
Halogenated anaesthetics (e.g. cyclopropane, desflurane, enflurane, isoflurane, sevoflurane) - increased cardiac autonomic irritability and risk of arrhythmias (US labelling)
Antidiabetic drugs - noradrenaline can decrease insulin sensitivity and raise blood glucose; monitor glucose and consider dosage adjustment (US labelling)

Clinical monograph

How it works

It is a predominantly alpha-1 adrenergic agonist causing intense peripheral vasoconstriction, with modest beta-1 activity providing some inotropic and chronotropic support.

Prescribing in practice

Administer only as a titrated continuous infusion through a central venous catheter wherever feasible, as extravasation causes severe local vasoconstriction and tissue necrosis; manage extravasation promptly with an alpha-blocker such as phentolamine.
Reserve for use in a critical-care or resuscitation environment with continuous invasive blood-pressure and cardiac monitoring, and correct hypovolaemia before relying on the vasopressor.
Excessive vasoconstriction can compromise renal, mesenteric and peripheral perfusion and provoke reflex bradycardia or arrhythmia.

Monitoring

Requires continuous invasive arterial blood-pressure, heart-rate and rhythm monitoring with frequent assessment of tissue perfusion, urine output and the infusion site.

Counselling the patient

Explain to the patient and family that this medicine supports blood pressure and is given via a drip in intensive care.
Alert the team immediately to any pain, swelling or colour change at the cannula site.

Evidence & guidelines

The SOAP II trial established noradrenaline as the preferred first-line vasopressor over dopamine in shock owing to fewer arrhythmic events, and it is endorsed as first-line in surviving-sepsis and cardiogenic-shock guidance.

Reference: SOAP II Trial (De Backer et al. NEJM 2010); ESC Cardiogenic Shock Guidelines; Surviving Sepsis Campaign 2021; SPC Noradrenaline; 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