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Vasopressor / Cardiogenic Shock Pregnancy: Use only for life-threatening maternal hypotension — vasopressors cross placenta; phenylephrine preferred in obstetric anaesthesia (less fetal acidosis). Specialist decision.

Noradrenaline (Cardiogenic Shock / Vasopressor)

Brand names: Noradrenaline (Levophed)

Adult dose

Dose: Initial: 0.01-0.1 mcg/kg/min IV; titrate to maintain MAP >=65 mmHg. Usual range: 0.01-3 mcg/kg/min.
Route: Intravenous infusion via CENTRAL venous access only
Frequency: Continuous infusion — titrated to haemodynamic response
Max: 3 mcg/kg/min (higher doses may be used in refractory shock with specialist input)
Predominant alpha-1 agonist with beta-1 activity. Increases SVR (vasoconstriction) — raises BP. Also increases cardiac contractility (beta-1). MUST be given via central venous catheter — peripheral extravasation causes severe tissue necrosis.

Paediatric dose

Dose: 0.01-1 mcg/min/kg
Route: IV central access only
Frequency: Continuous infusion
Max: Per haemodynamic response
Specialist paediatric intensive care only. BNFc for guidance.

Dose adjustments

Renal

No dose adjustment — titrate to haemodynamic response

Hepatic

No dose adjustment — titrate to haemodynamic response

Paediatric weight-based calculator

Specialist paediatric intensive care only. BNFc for guidance.

Clinical pearls

  • SOAP II trial (De Backer et al. NEJM 2010): noradrenaline vs dopamine as first-line vasopressor in shock — no overall 28-day mortality difference, but dopamine significantly more arrhythmias (24.1% vs 12.4%). Noradrenaline is now the preferred first-line vasopressor in cardiogenic and septic shock.
  • Extravasation emergency: if noradrenaline extravasates peripherally — dilute phentolamine 5-10 mg in 10 mL NS and inject subcutaneously into the affected area within 12 hours. This alpha-blockade prevents tissue necrosis.
  • Cardiogenic shock combination: noradrenaline raises MAP (allows coronary perfusion pressure); dobutamine adds inotropy (improves cardiac output). The combination is standard in cardiogenic shock with both hypotension and low CO.
  • Central line mandatory: noradrenaline should ONLY be administered via central venous catheter. If no central access in emergency, a large peripheral cannula in a large antecubital vein may be used short-term with close monitoring for extravasation.
  • Target MAP: maintain MAP >=65 mmHg (evidence-based threshold from sepsis trials — below this threshold, organ perfusion critically impaired). Higher MAP targets (>75 mmHg) not shown to improve outcomes except in patients with chronic hypertension.

Contraindications

  • Hypovolaemia (treat before using vasopressors — noradrenaline in hypovolaemia worsens organ perfusion)
  • Peripheral vascular disease (relative — severe vasoconstriction can worsen ischaemia)
  • Mesenteric ischaemia
  • Hypersensitivity

Side effects

  • Hypertension (dose-related)
  • Reflex bradycardia (baroreceptor response to raised BP)
  • Peripheral vasoconstriction — digital ischaemia, mesenteric ischaemia at high doses
  • Tissue necrosis (extravasation from peripheral IV — phentolamine injection for treatment)
  • Tachycardia (at high doses)
  • Headache

Interactions

  • MAOIs — severe hypertensive crisis; avoid
  • Tricyclic antidepressants — potentiate vasopressor response
  • Alpha-blockers (phentolamine, doxazosin) — antagonise vasoconstriction; phentolamine used to treat extravasation

Monitoring

  • Continuous arterial line BP monitoring (preferred to cuff)
  • Heart rate and rhythm
  • MAP target >=65 mmHg
  • Urine output (renal perfusion marker)
  • Signs of peripheral ischaemia (digits, abdomen)
  • IV site for extravasation

Reference: BNFc; BNF 90; SOAP II Trial (De Backer et al. NEJM 2010); ESC Cardiogenic Shock Guidelines; Surviving Sepsis Campaign 2021; SPC Noradrenaline. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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