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

Noradrenaline (Norepinephrine)

Brand names: Levophed

Noradrenaline (norepinephrine) is a potent endogenous catecholamine used intravenously as the first-line vasopressor for septic and other vasodilatory shock.

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. Recommended maintenance range of noradrenaline base is 0.05-1.5 micrograms/kg/min.

Route: Intravenous use only - administer as an intravenous infusion via a central venous catheter, using an infusion pump or syringe pump

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

There is great individual variation in the dose required to attain and maintain normotension. Aim 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). Blood pressure should be monitored carefully for the duration of therapy, preferably by arterial blood pressure monitoring. 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. The 0.08 mg/ml presentation is supplied ready to use - should not be diluted before use and should not be mixed with other medicines. Duration: continue until high-dose vasoactive drug support is no longer indicated, then gradually decrease the infusion and switch to an infusion of lower concentration - abrupt withdrawal can result in acute hypotension. Paediatric population: indicated for adults only; efficacy and safety in children and adolescents have not been established. Source product: Noradrenaline (Norepinephrine) 0.08 mg/ml solution for infusion (UK SPC). The SPC also gives a weight-based rate table (50-100 kg) converting micrograms/kg/min to mg/hour and ml/hour for the 0.08 mg/ml presentation.

Dose adjustments

Renal

No dose adjustment is specified - the SPC states 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
Concomitant use with cyclopropane and halothane anaesthetics - may cause serious cardiac arrhythmias including ventricular fibrillation
Administration via peripheral cannula and/or peripheral vein

Side effects

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

Interactions

Cyclopropane and halothane anaesthetics - contraindicated; may cause serious cardiac arrhythmias including ventricular fibrillation (stated in SPC section 4.3, cross-referencing section 4.5; the full section 4.5 text was not captured in this source bundle)

Clinical monograph

How it works

It is a predominantly alpha-1 adrenoceptor agonist with some beta-1 activity, producing vasoconstriction that raises systemic vascular resistance and mean arterial pressure with relatively modest effects on heart rate.

Prescribing in practice

Give as a continuous infusion through a central venous catheter wherever possible, because extravasation causes severe local vasoconstriction and tissue necrosis.
Titrate the infusion to a target blood pressure under continuous haemodynamic monitoring, and never stop the infusion abruptly without weaning.
Ensure adequate fluid resuscitation alongside the vasopressor and treat the underlying cause of shock.

Monitoring

Continuously monitor blood pressure (ideally invasively), heart rate, perfusion and the cannula site for signs of extravasation throughout the infusion.

Counselling the patient

Explain to the patient or family that this medicine supports blood pressure during critical illness.
Brief the team that the drug must run through a secure, preferably central, line and be checked frequently for tissue leakage.
Note that the infusion is weaned gradually as the patient improves.

Evidence & guidelines

International sepsis guidance, including the Surviving Sepsis Campaign, recommends noradrenaline as the first-choice vasopressor in septic shock.

Reference: Surviving Sepsis Campaign 2021; SOAP II Trial NEJM 2010; NICE; 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.

Drugs

Pathways

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Featured in these MRCEM clinical pathways

Noradrenaline (Norepinephrine) is a core drug in the following exam-focused workups on our sister siteReviseMRCEM.

MRCEM Primary / Intermediate / OSCE candidates: each pathway includes exam-style questions, RCEM/NICE citations, and FAQ summaries.