Page 155 - 2026 SMOG

NOREPINEPHRINE (LEVOPHED)
Class/Mechanism of Action
• Alpha and Beta Agonist
Stimulates beta and alpha-adrenergic receptors, increasing contractility, heart rate, and vasoconstriction.
1
Increases systemic blood pressure and coronary blood flow. Effects on vasoconstriction (alpha receptors)
are greater than on inotropic (beta receptors).
˚ Onset of action—IV: Very rapid. Duration: 1–2min
Indications
• Labeled Indications
Treatment of shock persisting after adequate fluid volume replacement; severe hypotension
˚ ALS 2020: Severe cardiogenic shock and hemodynamically significant hypotension (SBP <70mmHg)
˚ with low total peripheral resistance. Agent of last resort for management of ischemic heart disease
and shock.
Contraindications
• Hypersensitivity to norepinephrine, bisulfites, or any component of the formulation
• Hypotension from hypovolemia, except as an emergency measure to maintain coronary and cerebral
perfusion until volume can be replaced
Adverse Reactions/Precautions
• No applicable use in hemorrhagic shock unless fluid replacement therapy is maximized! Maximize
the use of blood products/crystalloids before considering their use in hemorrhagic shock.
• Strong vesicant; causes blisters: Ensure proper catheter placement and avoid extravasation; use a large
vein (preferably a central line) and avoid leg veins.
• Ensure adequate circulatory volume to minimize the need for vasoconstrictors. Monitor BP closely, avoid
hypertension, and adjust infusion rate as needed.
• Pregnancy: Category C
• Lactation: Use caution
Dose/Administration
PEDIATRIC
ADULT
(Always reference Broselow Tape)
Hypotension/Shock Hypotension/Shock
• IV (Administer as a continuous infusion with • IV Continuous Infusion
an infusion pump. Do not use in the same 0.05–0.2mcg/kg/min; titrate to effect (max
line as sodium bicarbonate; it will inactivate ˚ dose: 2mcg/kg/min)
norepinephrine)
5–15mcg/min; titrate to SBP goal
˚ ˚ Cardiogenic Shock: 5–20mcg/min
Post ROSC Hypotension
• IV
0.1–0.5mcg/kg/min titrate to effect
˚ If unable to maintain SBP >90 and MAP
˚ >65mmHg, add Epinephrine infusion
Use in Burn Patients
• IV
2–20mcg/min; only used when target MAP
˚ (>65mmHg) and UOP (>30mL/hr) fail to
be reached with fluid resuscitation alone. Its
sequence of use follows the administration of
Vasopressin
(See infusion chart on the next page for mix and
dosage information)
2026 Standard Medical Operating Guidelines (SMOG) • 147