Norepinephrine

Nick Rathert, MD

For the REMO Medical Advisory Committee

Norepinephrine (Levophed®)

• Classification: Adrenergic agent

• Onset: Rapid (1-2 minutes max)

• Duration of action: Short (1-2 minutes)

Background

• Previously viewed as one of many options for hypotension

– Pressor of choice for essentially all hypotension

– Surviving Sepsis treatment of choice

Adrenergic Mechanism

• Beta 1 – stimulates cardiac rate and contractility

• Alpha 1 – stimulates peripheral vasoconstriction

• Beta 2 – no effect on airway smooth muscle

Goals of Care

• Reversal of shock state

– A state of tissue hypoperfusion

• Increase perfusion to end organs via increased systemic vascular resistance

• Good initial BLS is paramount – recognition

• Good ALS is key – fluid resuscitation

• Don’t squeeze the pipes until the tank is full!

Indications?

Nearly Any Shock State!!ROSC

Neurogenic

Cardiogenic/LVAD

Anaphylactic

Septic

BUT – Correct Volume First

Contraindications

• There are no clear contraindications for norepinephrine in EMS

• Relative contraindication would be depleted intravascular volume

– Patient must receive appropriate fluid resuscitation first

Cautions

• Remember to “fill the tank” before you add a pressor

• Must ensure and reevaluate access

– Infiltration can lead to severe tissue necrosis

– If infiltration is suspected, stop drip immediately and notify hospital staff upon arrival

Specific information

• No pre-mix available

• Hospital concentrations will vary

• Supplied: 1mg/ml in 4 ml vial

• Dosing: Continuous Infusion

• Pregnancy category C

Administration

• Supplied as 4 mg in 4 ml

• Mix into NS 1,000 ml

• 4 mg in 1000ml = 4 mcg/ml

• Dosing? Start at 2 mcg/min or 0.5 to 5 ml/minute

– Titrate to a maximum of 20 mcg/min MAP >65

Protocol

Protocols

Thanks.