Alpha/Beta-1 Adrenoceptor Agonist — Vasopressor
Pregnancy: Use in life-threatening emergency only — vasoconstrictive effect reduces uterine blood flow; fetal bradycardia risk; obstetric specialist input required.
Noradrenaline (Burns Shock — Vasopressor)
Brand names: Noradrenaline Tartrate, Levophed
Adult dose
Dose: 0.01–3 mcg/kg/min IV infusion; titrated to MAP ≥65 mmHg; usual effective range 0.05–0.5 mcg/kg/min
Route: IV infusion via central line (peripheral line only in emergency)
Frequency: Continuous infusion — titrate to haemodynamic response
Max: No absolute maximum — titrate to response; >1 mcg/kg/min usually indicates refractory shock requiring additional agents
First-line vasopressor for haemodynamic support in major burns — used when adequate fluid resuscitation (Parkland formula) fails to maintain MAP ≥65 mmHg. Burns patients develop distributive shock from massive vasodilatation — noradrenaline restores vascular tone. Burn wound creates inhalation injury risk and systemic inflammatory response.
Paediatric dose
Dose: 0.01–1 mcg/min/kg
Route: IV infusion
Frequency: Continuous
Max: 1 mcg/kg/min (paediatric — higher doses under specialist guidance)
Paediatric burns shock: 0.1 mcg/kg/min starting dose; titrate to MAP appropriate for age. BNFc and PALS guidelines.
Dose adjustments
Renal
No dose adjustment — titrate to haemodynamic response. Reduced renal perfusion in shock requires careful MAP management.
Hepatic
No dose adjustment required.
Paediatric weight-based calculator
Paediatric burns shock: 0.1 mcg/kg/min starting dose; titrate to MAP appropriate for age. BNFc and PALS guidelines.
Clinical pearls
- Burns shock mechanism: unlike haemorrhagic shock (volume depletion primary), burns shock has a distributive component from massive cytokine-mediated vasodilation. Fluid resuscitation alone (Parkland formula: 3–4 mL/kg/% TBSA in 24h) is first-line — noradrenaline should only be added when MAP <65 mmHg despite adequate fluid loading to avoid excessive fluid creep
- Fluid creep problem: over-resuscitation in burns (oedema in unburned tissues, pulmonary oedema, abdominal compartment syndrome) worsens outcomes. Vasopressors allow reduced fluid volumes — early use of low-dose noradrenaline to permit 'fluid-sparing' resuscitation is increasingly practiced in specialist burns centres
- Inhalation injury and ARDS: burns with inhalation injury frequently develop ARDS — noradrenaline supports systemic perfusion during lung-protective ventilation (permissive hypercapnia; low tidal volumes); target MAP 65–70 mmHg to avoid excessive vasoconstriction
Contraindications
- Hypovolaemia (relative — noradrenaline in an underfilled patient causes extreme vasoconstriction and organ ischaemia; fluid resuscitation must precede vasopressor use)
- Vascular thrombosis (mesenteric or limb — may worsen ischaemia)
Side effects
- Peripheral ischaemia (digital, mesenteric — at high doses)
- Tissue necrosis (extravasation — central line preferred; antidote: phentolamine 5–10 mg SC around extravasation site)
- Tachyarrhythmias
- Hypertension (overdose)
- Reflex bradycardia
Interactions
- MAOIs (absolute contraindication — hypertensive crisis)
- Tricyclics (potentiate vasopressor effect — extreme hypertension)
- Halothane/volatile agents (myocardial sensitisation — arrhythmias)
Monitoring
- Continuous intra-arterial BP monitoring (radial arterial line)
- Urine output (0.5–1 mL/kg/hour — organ perfusion marker)
- Lactate (tissue perfusion adequacy — target <2 mmol/L)
- Digital perfusion (peripheral ischaemia)
- IV site (extravasation risk — central line preferred)
Reference: BNFc; BNF 90; British Burns Association Fluid Resuscitation Guidelines; Surviving Sepsis Campaign 2021; BNFc; NICE NG24 (Burns). Verify against your local formulary and the latest BNF before prescribing.
Related
Curated clinical cross-links plus same-class fallbacks.