General

High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error.

Pronunciation
NOR-ep-i-nef-rin


Trade Name(s)

• Levophed

Pregnancy Category
Category C

Ther. class.
vasopressors

Indications

Produces vasoconstriction and myocardial stimulation, which may be required after adequate fluid replacement in the treatment of severe hypotension and shock

Action

• Stimulates alpha-adrenergic receptors located mainly in blood vessels, causing constriction of both capacitance and resistance vessels

• Also has minor beta-adrenergic activity (myocardial stimulation)

Therapeutic Effect(s):

• Increased blood pressure

• Increased cardiac output

Pharmacokinetics

Absorption: IV administration results in complete bioavailability

Distribution: Concentrates in sympathetic nervous tissue. Does not cross the blood-brain barrier but readily crosses the placenta

Metabolism and Excretion: Taken up and metabolized rapidly by sympathetic nerve endings

Half-life: Unknown

TIME/ACTION PROFILE (effects on blood pressure)

ROUTE	ONSET	PEAK	DURATION
IV	immediate	rapid	1–2 min

Contraindication/Precautions

Contraindicated in:

• Vascular, mesenteric, or peripheral thrombosis

• OB: J uterine blood flow

• Hypoxia

• Hypercarbia

• Hypotension secondary to hypovolemia (without appropriate volume replacement)

• Hypersensitivity to bisulfites

Use Cautiously in:

• Hypertension

• Concurrent use of MAO inhibitors, tricyclic antidepressants, or cyclopropane or halothane anesthetics

• Hyperthyroidism

• Cardiovascular disease

• Lactation: Safety not established

Adverse Reactions/Side Effects

CNS: anxiety, dizziness, headache, insomnia, restlessness, tremor, weakness.

Resp: dyspnea.

CV: arrhythmias, bradycardia, chest pain, hypertension.

GU: decreased urine output, renal failure.

Endo: hyperglycemia.

F and E: metabolic acidosis.

Local: phlebitis at IV site.

Misc: fever.

*CAPITALS indicates life-threatening.
*italic indicates most frequent.

Interactions

Drug-Drug

• Use with cyclopropane or halothane anesthesia , cardiac glycosides , doxapram , or local use of cocaine may result in ↑ myocardial irritability

• Use with MAO inhibitors , methyldopa , doxapram , or tricyclic antidepressants may result in severe hypertension

• Alpha-adrenergic blockers can prevent pressor response

• Beta blockers may exaggerate hypertension or block cardiac stimulation

• Concurrent use with ergot alkaloids ( ergotamine , ergonovine , methylergonovine , or oxytocin may result in enhanced vasoconstriction and hypertension

Route/Dosage

• IV (Adults): 0.5–1 mcg/min initially, followed by maintenance infusion of 2–12 mcg/min titrated by blood pressure response (average rate 2–4 mcg/min, up to 30 mcg/min for refractory shock have been used).

• IV (Children): 0.1 mcg/kg/min initially; may be followed by infusion titrated to blood pressure response, up to 1 mcg/kg/min.

Availability

• Injection: 1 mg/mL in 4-mL ampules

Assessment

• Monitor blood pressure every 2–3 min until stabilized and every 5 min thereafter. Systolic blood pressure is usually maintained at 80–100 mm Hg or 30–40 mm Hg below the previously existing systolic pressure in previously hypertensive patients. Consult physician for parameters. Continue to monitor blood pressure frequently for hypotension following discontinuation of norepinephrine

• ECG should be monitored continuously. CVP, intra-arterial pressure, pulmonary artery diastolic pressure, pulmonary capillary wedge pressure (PCWP), and cardiac output may also be monitored

• Monitor urine output and notify health care professional if it decreases to <30 mL/hr

• Assess IV site frequently throughout infusion. A large vein should be used to minimize risk of extravasation, which may cause tissue necrosis. Phentolamine 5–10 mg may be added to each liter of solution to prevent sloughing of tissue in extravasation. If extravasation occurs, the site should be infiltrated promptly with 10–15 mL of 0.9% NaCl solution containing 5–10 mg of phentolamine to prevent necrosis and sloughing. If prolonged therapy is required or if blanching along the course of the vein occurs, change injection sites to provide relief from vasoconstriction

Toxicity and Overdose

• If overdose occurs, discontinue norepinephrine and administer fluid and electrolyte replacement therapy. An alpha-adrenergic blocking agent (phentolamine 5–10 mg) may be administered intravenously to treat hypertension

Potential Nursing Diagnoses

• Decreased cardiac output (Indications)

• Ineffective tissue perfusion (Indications)

Implementation

• High Alert: Vasoactive medications are inherently dangerous. Have second practitioner independently check original order, dose calculations, and infusion pump programming. Establish maximum dose limits. Norepinephrine overdose can result in severe peripheral vasoconstriction with resultant ischemia and necrosis of peripheral tissue. Assess peripheral circulation frequently

• Volume depletion should be corrected, if possible, prior to initiation of norepinephrine

» Heparin may be added to each 500 mL of solution to prevent thrombosis in the infused vein, perivenous reactions, and necrosis in patients with severe hypotension following MI

» Norepinephrine may deplete plasma volume and cause ischemia of vital organs, resulting in hypotension when discontinued, if used for prolonged periods. Prolonged or large doses may also decrease cardiac output

» Infusion should be discontinued gradually, upon adequate tissue perfusion and maintenance of blood pressure, to prevent hypotension. Do not resume therapy unless blood pressure falls to 70–80 mm Hg

IV Adminstration:

• Continuous Infusion:

Diluent: Dilute 4 mg in 1000 mL of D5W or D5/0.9% NaCl. Do not dilute in 0.9% NaCl without dextrose
Concentration: 4 mcg/mL Do not use discolored solutions (pink, yellow, brown) or those containing a precipitate

• Rate:
Titrate infusion rate according to patient response, using slowest possible rate to correct hypotension. Administer via infusion pump to ensure accurate dosage

• Y-Site Compatibility:

» alfentanil

» amikacin

» amiodarone

» anidulafungin

» argatroban

» ascorbic acid

» atracurium

» atropine

» benztropine

» bivalirudin

» bumetanide

» buprenorphine

» butorphanol

» calcium chloride

» calcium gluconate

» carboplatin

» caspofungin

» cefazolin

» cefonicid

» cefoperazone

» cefotaxime

» cefotetan

» cefoxitin

» ceftazidime

» ceftizoxime

» ceftriaxone

» cefuroxime

» chloramphenicol

» chrlopromazine

» cimetidine

» cisatracurium

» cisplatin

» clindamycin

» cyanocobalamin

» cyclophosphamide

» cyclosporine

» cytarabine

» daptomycin

» dexamethasone

» digoxin

» diltiazem

» diphenhydramine

» dobutamine

» docetaxel

» dopamine

» doripenem

» doxycycline

» enalaprilat

» ephedrine

» epinephrine

» epirubicin

» epoetin alfa

» ertapenem

» erythromycin

» esmolol

» etoposide

» etoposide phosphate

» famotidine

» fenoldopam

» fentanyl

» fluconazole

» fludarabine

» gemcitabine

» gentamicin

» glycopyrrolate

» granisetron

» heparin

» hetastarch

» hydrocortisone sodium succinate

» hydromorphone

» ifosfamide

» imipenem/cilastatin

» isoproterenol

» ketorolac

» labetalol

» lidocaine

» linezolid

» lorazepam

» magnesium sulfate

» mannitol

» mechlorethamine

» meperidine

» meropenem

» metaraminol

» methotrexate

» methoxamine

» methyldopate

» methylprednisolone

» metoclopramide

» metoprolol

» metronidazole

» micafungin

» miconazole

» midazolam

» milrinone

» mitoxantrone

» morphine

» multivitamins

» mycophenolate

» nafcillin

» nalbuphine

» naloxone

» nicardipine

» nitroglycerin

» nitroprusside

» octreotide

» ondansetron

» oxacillin

» oxaliplatin

» oxytocin

» paclitaxel

» palonosetron

» papaverine

» pemetrexed

» penicillin G

» pentamidine

» pentazocine

» phentolamine

» phenylephrine

» phytonadione

» piperacillin/tazobactam

» potassium chloride

» procainamide

» prochlorperazine

» promethazine

» propofol

» propranolol

» protamine

» pyridoxime

» ranitidine

» remifentanil

» streoptokinase

» succinylcholine

» sufentanil

» tacrolimus

» teniposide

» theophylline

» thiamine

» thiotepa

» ticarcillin/clavulanate

» tigecycline

» tirofiban

» tobramycin

» tolazoline

» trimetaphan

» urokinase

» vancomycin

» vasorpessin

» vecuronium

» verapamil

» vincristine

» vinorelbine

» vitamin B complex with C

» voriconazole

• Y-Site Incompatibility:
aminophylline
amphotericin B colloidal
azathioprine
dantrolene
diazepam
diazoxide
drotrecogin
folic acid
ganciclovir
indomethacin
pentobarbital
phenobarbital
phenytoin
sodium bicarbonate
thiopental
trimethoprim/sulfamethoxazole

Patient/Family Teaching

Instruct patient to report headache, dizziness, dyspnea, chest pain, or pain at infusion site promptly

Evaluation/Desired Outcomes

Increase in blood pressure to normal range

» Increased tissue perfusion

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