Bedside Snapshot
- Use It For
- Septic shock (first-line); cardiogenic shock with an inotrope; post–cardiac arrest hypotension; neurogenic or vasodilatory shock
- Adult Dose
- Septic shock: start 0.05–0.1 mcg/kg/min IV, usual 0.05–0.5 mcg/kg/min to MAP 65 mmHg (no fixed max)
- Label fixed rate: 8–12 mcg/min IV, maintenance 2–4 mcg/min
- Pediatric Dose
- 0.05–0.5 mcg/kg/min IV/IO to SBP ≥5th percentile, strong pulses, cap refill under 2 sec. PICU to 2 (differs from FDA label). NASEMSO prefers in septic and neurogenic shock; SSC 2026 children: no preference.
- Onset / Duration
- IV infusion: 1–2 min (steady state about 5 min) / effect ends 1–2 min after stopping
- Do Not Give / Hold If
- No absolute label contraindications. Hold or move the line if the site swells or blanches; reduce if digits mottle; wean when MAP is above goal
- Watch For
- Extravasation (blanching, swelling at site); digital, limb or gut ischemia (mottling, rising lactate); arrhythmias on ECG; hypertension with reflex bradycardia
- Reversal / Rescue
- Effect ends 1–2 min after stopping. Extravasation: phentolamine 5–10 mg in 10–15 mL 0.9% NaCl infiltrated into the site within 12 hr
- Must Remember
- mcg/kg/min is not mcg/min: 0.1 mcg/kg/min in an 80-kg adult is 8 mcg/min. Confirm units, concentration and dosing weight on the pump; never flush the line
Indications
Emergency & Prehospital
- Septic shock: the first-line adult vasopressor. You can start it peripherally (see sepsis and septic shock)
- Post–cardiac arrest hypotension: after ROSC, the target is MAP ≥65 mmHg (see post–cardiac arrest care)
- Cardiogenic shock: the pump is failing. Add dobutamine or milrinone when output stays low
- Neurogenic shock: hypotension with bradycardia after acute traumatic spinal cord injury. Exclude hemorrhage first (see shock states)
- Refractory anaphylactic shock: an adjunct. It comes after IM and IV epinephrine and fluids
ED / ICU / Transport
- Pediatric septic shock: NASEMSO and SSC 2026 don't agree (see Pediatric Shock)
- Vasodilatory hypotension: anesthesia and post-cardiac-surgery vasoplegia. The FDA label covers acute hypotension in adults
Not a cardiac arrest drug: no role during CPR. If hypotension persists after ROSC, start it then.
Dosing & Administration
Doses vary by protocol; follow local protocols and medical direction.
Available Forms
- Concentrate: 1 mg/mL in 4 mL (4 mg) as base (bitartrate salt); dilute before use
- Premixed bags: 4, 8, 16 or 32 mg/250 mL (16, 32, 64 or 128 mcg/mL) in 0.9% NaCl or D5W
- Label dilution: 4 mg in 1,000 mL D5W or D5/0.9% NaCl (4 mcg/mL)
High-Alert Medication: the units are the trap. mcg/min and mcg/kg/min differ 80-fold in an 80-kg adult. The other traps are the wrong concentration in the pump library and a bolus from flushing. Double-check drug, concentration, dosing weight, units and rate at the start, at each bag change and at handoff.
Adult Dosing
| Indication | Dose & Route | Repeat / Max | Notes |
|---|---|---|---|
| Septic shock (weight-based) | Start 0.05–0.1 mcg/kg/min IV; usual 0.05–0.5 mcg/kg/min | Titrate every 2–5 min to MAP 65 mmHg (60–65 if ≥65 yr); no fixed max | High-alert Add vasopressin at escalating doses. Common practice steps 0.02–0.05 mcg/kg/min |
| Acute hypotension (FDA label) | 8–12 mcg/min IV; maintenance 2–4 mcg/min | Adjust to effect; no fixed max | High-alert Fixed rate: never mix mcg/min and mcg/kg/min orders on one patient |
| Cardiogenic or post–cardiac arrest | 0.05–0.5 mcg/kg/min IV to MAP ≥65 mmHg and perfusion | No fixed max | High-alert Cardiogenic: add an inotrope. Post-arrest: AHA 2025 finds insufficient evidence to recommend a specific vasopressor |
| Neurogenic (acute traumatic spinal cord injury) | 0.05–0.5 mcg/kg/min IV to the spinal cord injury MAP goal | MAP 75–80 mmHg (not above 90–95) for 3–7 days | High-alert Exclude hemorrhage first; goals are low-evidence |
Dosing weight: usually actual body weight. Say which weight you used at handoff.
Pump rate (weight-based)
mL/hr = mcg/kg/min × kg × 60 ÷ mcg/mL. Example: 0.1 × 80 × 60 ÷ 16 = 30 mL/hr
Pediatric Dosing
| Indication | Dose (per kg) & Route | Max Single / Max Total | Notes |
|---|---|---|---|
| Fluid-refractory septic shock | 0.05–0.5 mcg/kg/min IV/IO to SBP at least the 5th percentile for age, strong distal pulses, capillary refill under 2 sec | Differs from FDA label: PICU titrates above 0.5 (to 2) | High-alert NASEMSO: preferred in neurogenic and septic distributive shock. SSC 2026 children: insufficient evidence to prefer |
| Post–cardiac arrest or vasodilatory hypotension | 0.05–0.5 mcg/kg/min IV/IO | Titrate to effect; Differs from FDA label (PICU, to 2) | High-alert Age-based BP targets (see Pediatric Vital Signs) |
| Neonates | Specialist use only | — | Neonatal intensivist and pharmacy dosing only; not for prehospital use |
Not FDA-established in children. The range comes from NASEMSO v3.0 (Shock, p. 109). The FDA label gives no pediatric dose.
Preparation & Administration
- Dilution: premixed bag when available; label diluent D5W or D5/0.9% NaCl. Discard if pinkish, darker than slightly yellow, or precipitate forms.
- Pump: smart pump with drug library on a dedicated line; never IV push or flush.
- Peripheral: 20 gauge or larger in a proximal vein (not hand, wrist or leg); confirm blood return; site check at least hourly.
- Central: for escalating doses, a second vasopressor or prolonged infusion; no safe peripheral duration or dose is established.
- IO: temporary route when no IV is available.
NE-eq dose (mcg/kg/min) = norepinephrine + epinephrine + dopamine ÷ 100 + phenylephrine × 0.06 + vasopressin (units/min) × 2.5. US doses are the base. Some countries dose the tartrate salt, so 2 mg of salt is about 1 mg of base.
Contraindications & Precautions
Contraindications
- None absolute on the FDA label. In life-threatening shock, the benefit usually outweighs the risk.
- Mesenteric or peripheral vascular thrombosis (relative). Avoid it unless the drug is needed to sustain life.
- Sulfite allergy (relative). Some products contain sodium metabisulfite.
Precautions
- Hypovolemia: fix the volume deficit. While MAP is critically low, the pressor and fluids may run together.
- Peripheral vascular disease, older adults: avoid the leg veins.
- Hypoxia, hypercarbia, arrhythmias: these raise ventricular arrhythmia risk. Correct them and monitor.
Hold / Reassess If
- MAP above target (over about 5 mmHg) twice? Wean it. Don't stop it abruptly.
- Swelling, blanching, coolness or pain at a site: stop. Move the infusion to another line and treat the extravasation.
- New tachyarrhythmia, ischemic ECG change or mottled digits: reassess the dose, volume and output.
- MAP below goal on escalating doses: add vasopressin, check cardiac function and consider corticosteroids. Don't escalate one drug alone.
Never let the pressure crash while you fix the line: get a new vein or IO going first, then restart.
Adverse Effects & Toxicity
Common
- Hypertension and reflex bradycardia (most common label reactions)
- Headache, anxiety; respiratory difficulty, pulmonary edema
- Tachyarrhythmias, palpitations; hyperglycemia (see Interactions)
Serious / Life-Threatening
| Effect | Recognition | Management |
|---|---|---|
| Extravasation necrosis | Blanching, swelling, cool skin or pain | Stop, aspirate, remove catheter, restart elsewhere; phentolamine 5–10 mg in 10–15 mL 0.9% NaCl infiltrated through the area as soon as possible (within 12 hr) |
| Digital, limb or mesenteric ischemia | Mottled digits, absent pulses, abdominal pain, rising lactate | Lowest effective dose, add vasopressin, check volume and output; surgical review |
| Arrhythmias | New AF, ventricular ectopy, VT | Correct hypoxia, K⁺, Mg²⁺; reduce dose or add a second agent |
| Rebound hypotension | MAP falls after abrupt stop or line interruption | Restart, then taper gradually with IV fluids (label) |
Overdose & Toxicity Management
- Signs: severe hypertension, headache, reflex bradycardia, high peripheral resistance with falling cardiac output.
- Immediate: stop or reduce the infusion. The effect ends within 1–2 min.
- Antidote: none systemic. For extravasation, phentolamine goes in locally (pediatric dose is weight-based, per pharmacy). If it is unavailable, topical nitroglycerin or subcutaneous terbutaline are the off-label options.
Monitoring
| Parameter | When / How Often | Target / Act If |
|---|---|---|
| Clinical: blood pressure | Every 2 min while titrating, then every 5 min | MAP targets per Dosing; wean when above goal |
| Clinical: arterial line | Escalating doses, 2+ vasopressors, or unreliable cuff | Trust a well-damped trace (Hemodynamic Monitoring) |
| Clinical: ECG and perfusion | Continuous ECG; hourly mental status, capillary refill, urine | New tachyarrhythmia or ischemia: reassess dose and volume. Urine under 0.5 mL/kg/hr or cap refill over 3 sec at goal MAP: reassess output and volume |
| Laboratory: lactate | Baseline, then every 2–4 hr while elevated | Not falling: reassess perfusion; consider mesenteric ischemia |
| Laboratory: glucose | Every 1–4 hr per ICU protocol | >180 mg/dL: treat per insulin protocol |
| Infusion safety: total vasopressor dose | Each titration and at handoff | NE-eq climbing: add vasopressin, assess heart function, plan central access |
Interactions & Compatibility
Clinically Significant Interactions
| Drug / Class | Effect | What To Do |
|---|---|---|
| MAO inhibitors, including linezolid | Severe, prolonged hypertension | Avoid if possible; start low, titrate slowly |
| Tricyclic antidepressants | Severe, prolonged hypertension | Start low; arterial line if possible |
| Halogenated anesthetics | Ventricular tachycardia or fibrillation | Continuous ECG; treat arrhythmias promptly |
| Insulin and other antidiabetics | Hyperglycemia, reduced insulin sensitivity | Monitor glucose; adjust insulin |
| Other vasopressors and inotropes | Additive pressor and arrhythmia effects | Track total NE-eq dose; titrate one drug at a time |
IV Compatibility
- Avoid: sodium bicarbonate and other alkalis. They inactivate catecholamines. Iron salts and oxidizing agents too. Blood or plasma goes on a separate line.
- Verify with your institution's compatibility resource.
Special Populations
- Pediatrics: see Pediatric Dosing. Extravasation is more frequent at distal sites, such as the hand.
- Neonates: specialist use only. See Pediatric Dosing.
- Pregnancy: human data are limited, and they have not shown more birth defects or miscarriage. Don't withhold it in shock. High-dose animal studies showed reduced placental blood flow.
- Lactation: there are no data. Infant exposure is not expected to matter clinically.
- Older Adults: SSC 2026 suggests an initial MAP of 60–65 mmHg at age 65 or older in septic shock. After cardiac arrest, AHA 2025 keeps MAP at least 65 mmHg. It is not on the AGS Beers Criteria.
- Renal and Hepatic Impairment: no specific adjustment is established. Titrate to effect.
- Obesity / Dosing Weight: actual body weight inflates mcg/kg/min doses. Some protocols use ideal or adjusted weight, or mcg/min dosing. Pick one convention per patient and stick to it.
Field & Transport Considerations
- Scope: paramedic, RN and critical-care transport (CCT) use depends on local protocol. Peripheral starts vary by agency.
- Storage & Stability: 20–25°C (68–77°F) in the carton, protected from light; diluted 24 hr at room temperature; premixed in-use stability varies from 24 hours to 45 days (follow the bag label). Do not freeze.
- Infusions in Transport: run it on a dedicated pump channel. Confirm bag strength against the pump library, because a mismatch is a silent 2- to 8-fold dose error. Carry a spare bag before transfers. Check the site after every move.
- Handoff Essentials: start time, dose (mcg/kg/min or mcg/min, with dosing weight), concentration, last titration and MAP response, other vasopressors (NE-eq), line and site, extravasation and phentolamine given.
Clinical Pearls
When to add vasopressin: SSC 2026 suggests adding it as norepinephrine doses escalate. There is no fixed cut-off.
Other vasopressors:
- Vasopressin: V₁ add-on, catecholamine-sparing (vasopressin)
- Epinephrine: more β. It is the alternative with cardiac dysfunction or bradycardia, and it raises lactate (epinephrine)
- Phenylephrine: pure α₁. It may drop stroke volume and heart rate (phenylephrine)
- Dopamine: more arrhythmias. Not first-line (dopamine)
Exam discriminator: Here's the key distinction. Norepinephrine is first-line in septic and cardiogenic shock. Low output at an adequate MAP? Add dobutamine or epinephrine, not dopamine.
Pharmacology
Mechanism of Action
- α₁ agonism clamps the pipes: vasoconstriction, higher systemic vascular resistance and MAP. β₁ agonism squeezes harder and dilates the coronaries, so cardiac output is usually maintained.
- Minimal β₂ effect. Little vasodilation. Heart rate is often unchanged, or slower, through the baroreflex.
Pharmacokinetics
- Onset and duration: IV/IO onset 1–2 min; steady state in about 5 min; effect ends 1–2 min after stopping.
- Half-life: about 2.4 min. Protein binding / Vd: about 25% bound; volume of distribution about 8.8 L.
- Metabolism and elimination: COMT and MAO; urine, mainly as sulfate and glucuronide conjugates. No active metabolites (normetanephrine, vanillylmandelic acid).
Names & Classification
- Generic Name
- Norepinephrine bitartrate (doses expressed as norepinephrine base); levarterenol, noradrenaline
- Brand Names
- Levophed (US); generic vials and premixed bags
- Pharmacologic Class
- Catecholamine; α₁ and β₁ adrenergic agonist (sympathomimetic)
- Therapeutic Class
- Vasopressor
- Controlled Substance
- Not controlled
- ISMP High-Alert
- Yes: ISMP high-alert medication (adrenergic agonists, IV)
- Look-Alike / Sound-Alike
- Practical mix-up risk with epinephrine (similar name, same pumps); confirm drug and concentration at every handoff
References
- Hospira, Inc. (2025). LEVOPHED (norepinephrine bitartrate) injection, for intravenous use: prescribing information. DailyMed, U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c4de72a8-2a75-4984-ce90-e4870226dc12
- Prescott, H. C., Antonelli, M., Alhazzani, W., Møller, M. H., et al. (2026). Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2026. Critical Care Medicine. https://doi.org/10.1097/CCM.0000000000007075
- Weiss, S. L., Peters, M. J., Oczkowski, S. J. W., Belley-Cote, E., et al. (2026). Surviving Sepsis Campaign international guidelines for the management of sepsis and septic shock in children 2026. Pediatric Critical Care Medicine, 27(4), 379–434. https://doi.org/10.1097/PCC.0000000000003927
- Hirsch, K. G., Amorim, E., Coppler, P. J., Drennan, I. R., et al. (2025). Part 11: Post–cardiac arrest care: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 152(16 Suppl 2). https://doi.org/10.1161/CIR.0000000000001375
- Kotani, Y., Di Gioia, A., Landoni, G., Belletti, A., & Khanna, A. K. (2023). An updated norepinephrine equivalent score in intensive care as a marker of shock severity. Critical Care, 27, 29. https://doi.org/10.1186/s13054-023-04322-y
- Kwon, B. K., Tetreault, L. A., Martin, A. R., Arnold, P. M., et al. (2024). A clinical practice guideline for the management of patients with acute spinal cord injury: Recommendations on hemodynamic management. Global Spine Journal, 14(3 Suppl), 187S–211S. https://doi.org/10.1177/21925682231202348
- García-Uribe, J., Lopera-Jaramillo, D., Gutiérrez-Vargas, J., Arteaga-Noriega, A., et al. (2023). Adverse effects related with norepinephrine through short peripheral venous access: Scoping review. Enfermería Intensiva (English ed.), 34(4), 218–226. https://doi.org/10.1016/j.enfie.2022.09.001
- De Backer, D., Biston, P., Devriendt, J., Madl, C., et al. (2010). Comparison of dopamine and norepinephrine in the treatment of shock (landmark trial). New England Journal of Medicine, 362(9), 779–789. https://doi.org/10.1056/NEJMoa0907118
- National Association of State EMS Officials. (2022). National Model EMS Clinical Guidelines, Version 3.0 (March 2022): General Medical, Shock (pp. 108–110). https://nasemso.org/docs.ashx?id=1444322
Medical Disclaimer
- For Educational Purposes Only: This content is intended for educational reference and should not be used for clinical decision-making.
- Not a Substitute for Professional Judgment: Always consult your local protocols, institutional guidelines, and supervising physicians.
- Verify Before Acting: Users are responsible for verifying information through authoritative sources before any clinical application.
AI Assistance Notice
AI was used to assist in organizing, paraphrasing, and formatting this information.