Vasopressor Pregnancy: C — use for life-threatening maternal hypotension

Noradrenaline (Norepinephrine)

Brand names: Levophed

Adult dose

Dose: 0.01–3 mcg/kg/min infusion (titrate to MAP ≥65 mmHg)

Route: IV infusion — central line preferred

Frequency: Continuous infusion

Start 0.01–0.1 mcg/kg/min, titrate by 0.05 mcg/kg/min every 5–10 min. Typical concentration: 4mg/50ml (80mcg/ml) via syringe driver. Peripheral short-term acceptable (≤4h) in emergency — dilute to ≤4mcg/ml, large antecubital vein.

Dose adjustments

Renal

No specific adjustment — titrate to MAP.

Clinical pearls

First-line vasopressor for septic shock (Surviving Sepsis Campaign 2021 — Grade 1B evidence). Target MAP ≥65 mmHg.
Peripheral noradrenaline is acceptable short-term (<6h) in resuscitation — use largest antecubital vein, dilute to ≤4mcg/ml.
Extravasation treatment: phentolamine 5–10mg diluted in 10ml saline, infiltrate into affected site immediately.
Dopamine is NOT recommended as first-line vasopressor — more arrhythmias, no mortality benefit over noradrenaline (SOAP II trial).

Contraindications

Hypovolaemia — correct fluid deficit before or concurrently with vasopressor initiation
Peripheral vascular occlusive disease (relative)

Side effects

Hypertension, bradycardia (reflex)
Peripheral and mesenteric ischaemia at high doses
Tissue necrosis if extravasation — treat immediately
Increased cardiac afterload — may worsen low cardiac output states

Interactions

MAO inhibitors: severe hypertension
Beta-blockers: reflex bradycardia
Volatile anaesthetics: myocardial sensitisation to arrhythmias

Monitoring

Continuous arterial line (MAP)
cardiac output monitoring if available
urine output
lactate

Reference: Surviving Sepsis Campaign 2021; SOAP II Trial NEJM 2010; NICE BNF 84. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

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