Noradrenalin Aguettant (Norepinephrine)

Vasopressor infusion solution for emergency treatment of acute hypotension

Rx - Prescription Only Vasopressor / Sympathomimetic
Active Ingredient
Norepinephrine (norepinephrine tartrate)
Dosage Forms
Solution for infusion
Available Strengths
1 mg/ml, 0.08 mg/ml
Administration Route
Intravenous (central line only)
Known Brands
Noradrenalin Fresenius Kabi, Noradrenalin Zentiva, Noradrenalin Kalceks
Medically reviewed | Last reviewed: | Evidence level: 1A
Noradrenalin Aguettant is a vasopressor medication containing norepinephrine, used exclusively in hospital settings for the emergency treatment of acute hypotension (dangerously low blood pressure). Administered only through a central venous catheter as a continuous intravenous infusion, it is the first-line vasopressor recommended by international critical care guidelines for septic shock. This medication works by constricting blood vessels to restore adequate blood pressure and organ perfusion.
Published:
Reviewed:
Reading time: 12 minutes
Written by iMedic Medical Editorial Team | Critical Care Specialists

Quick facts about Noradrenalin Aguettant

Active Ingredient
Norepinephrine
as tartrate salt
Drug Class
Vasopressor
Sympathomimetic
Common Uses
Septic Shock
Acute hypotension
Available Forms
IV Infusion
0.08 mg/ml & 1 mg/ml
Prescription Status
Rx Only
Hospital use only
Administration
Central IV
Central venous catheter

Key Takeaways

  • First-line vasopressor for septic shock: Norepinephrine is recommended as the first-choice vasopressor by the Surviving Sepsis Campaign 2021 guidelines for hemodynamic support in septic shock
  • Central line administration only: Must be given through a central venous catheter; peripheral IV administration can cause severe tissue necrosis from extravasation
  • Continuous monitoring required: Blood pressure, heart rate, and the infusion site must be continuously monitored throughout treatment
  • Gradual dose tapering: Never stop norepinephrine abruptly, as this can cause acute life-threatening hypotension; always taper the dose gradually
  • Hospital use only: This medication is exclusively used in hospital settings, typically in intensive care units, and is administered by trained healthcare professionals

What Is Noradrenalin Aguettant and What Is It Used For?

Noradrenalin Aguettant contains the active substance norepinephrine (noradrenaline), a potent vasopressor that constricts blood vessels to raise blood pressure. It is used exclusively in adults weighing over 50 kg for the emergency treatment of acute hypotension (dangerously low blood pressure) when immediate blood pressure restoration is required.

Norepinephrine is a naturally occurring catecholamine produced by the adrenal medulla and sympathetic nerve endings. It plays a vital role in the body's "fight or flight" response by regulating blood pressure and blood flow. As a pharmaceutical agent, synthetic norepinephrine mimics the actions of this endogenous hormone, primarily stimulating alpha-1 adrenergic receptors on blood vessel walls to produce powerful vasoconstriction, thereby increasing both systolic and diastolic blood pressure.

In clinical practice, norepinephrine is the first-line vasopressor recommended by the Surviving Sepsis Campaign (SSC) 2021 guidelines for the management of septic shock. It is preferred over other vasopressors such as dopamine because it is more effective at restoring mean arterial pressure (MAP) and is associated with fewer adverse cardiac events, particularly fewer arrhythmias. The target MAP during norepinephrine therapy is typically 65 mmHg or above, though this may be adjusted based on the individual patient's condition and comorbidities.

Beyond septic shock, norepinephrine is used in a variety of critical care scenarios involving acute hypotension, including cardiogenic shock (when used in combination with inotropic agents), neurogenic shock following spinal cord injury, and post-cardiac surgery hypotension. Its potent alpha-adrenergic effects make it particularly useful when peripheral vascular resistance is low, as seen in distributive shock states.

The Noradrenalin Aguettant formulation is supplied as a ready-to-use solution for infusion at a concentration of 0.08 mg/ml, designed to be administered without prior dilution. This pre-diluted formulation reduces the risk of medication errors associated with manual dilution and simplifies the preparation process in time-critical emergency situations. A concentrated formulation at 1 mg/ml is also available and requires dilution before administration.

Important clinical note:

Norepinephrine should be used as part of a comprehensive hemodynamic management strategy. Adequate fluid resuscitation should be initiated before or concurrently with vasopressor therapy. Vasopressors alone cannot address hypovolemia, and their use without adequate volume replacement may worsen tissue perfusion and organ function.

What Should You Know Before Taking Noradrenalin Aguettant?

Noradrenalin Aguettant must never be administered through a peripheral intravenous line or peripheral vein. It is contraindicated in patients with known hypersensitivity to norepinephrine or any of its excipients. Several pre-existing conditions require careful consideration before initiating treatment.

Contraindications

Norepinephrine is contraindicated in the following situations:

  • Peripheral administration: Must never be given via a peripheral cannula or peripheral vein due to the risk of severe local tissue necrosis from extravasation
  • Known hypersensitivity: In patients with documented allergy to norepinephrine or any of the excipients (sodium chloride, disodium edetate, hydrochloric acid, sodium hydroxide, water for injections)

While these are absolute contraindications, clinicians must also weigh the risks and benefits in several relative contraindication scenarios. In life-threatening hypotensive emergencies, the potential benefit of restoring blood pressure may outweigh most relative risks. The treating physician must make this determination based on the specific clinical situation.

Warnings and Precautions

Special caution is required and additional monitoring may be necessary in patients with the following conditions:

  • Severe left ventricular dysfunction: Norepinephrine increases afterload (resistance against which the heart must pump), which can worsen cardiac function in patients with severe heart failure. Cardiac output monitoring is essential in these patients.
  • Recent myocardial infarction: The increased cardiac workload from norepinephrine-induced vasoconstriction and enhanced contractility may extend infarct size or provoke ischemia in vulnerable myocardial tissue.
  • Cardiac arrhythmias: Including tachycardia, bradycardia, and irregular rhythms. Norepinephrine has moderate beta-1 adrenergic activity that can exacerbate pre-existing arrhythmias.
  • Hyperthyroidism: Patients with overactive thyroid glands may have heightened cardiovascular sensitivity to catecholamines, increasing the risk of severe hypertension and tachyarrhythmias.
  • Diabetes mellitus: Norepinephrine can affect glucose metabolism and may exacerbate hyperglycemia. Blood glucose monitoring should be intensified during treatment.
  • Hypovolemic hypotension: Low blood pressure caused by reduced blood volume should primarily be treated with fluid replacement. Using norepinephrine without adequate volume resuscitation can worsen tissue ischemia.
  • Peripheral vascular disease: Including Raynaud's phenomenon or peripheral arterial occlusive disease. Norepinephrine's vasoconstrictive effects can critically reduce blood flow to already compromised extremities, potentially leading to gangrene.

During the infusion, the treating medical team will continuously monitor blood pressure, heart rate, cardiac rhythm, and the infusion site for signs of extravasation. If blood or plasma transfusion is necessary concurrently with norepinephrine, it must be administered as a separate infusion through a different line.

Extravasation warning:

If norepinephrine leaks from the vein into surrounding tissue (extravasation), it can cause severe local vasoconstriction leading to tissue ischemia and necrosis. If extravasation is suspected, the infusion must be stopped immediately, and the affected area should be infiltrated with phentolamine (an alpha-adrenergic blocker) as soon as possible. This is one of the primary reasons why norepinephrine must only be administered through a central venous catheter.

Pregnancy and Breastfeeding

Norepinephrine should only be used during pregnancy when the potential benefit to the mother outweighs the risk to the fetus. Animal and limited clinical data suggest that norepinephrine can reduce uterine blood flow, potentially compromising fetal oxygenation. The decision to use norepinephrine in pregnant patients is made on an individual basis by the treating physician, typically only in life-threatening situations where no safer alternative exists.

There is insufficient data regarding the excretion of norepinephrine into breast milk. Given that norepinephrine is used only in acute critical care settings, breastfeeding considerations are typically secondary to the immediate life-threatening condition being treated. Healthcare providers will advise on the appropriate timing to resume breastfeeding after treatment.

Use in Children and Adolescents

Noradrenalin Aguettant is intended for use in adults only. While norepinephrine is used off-label in paediatric intensive care, the Aguettant formulation at 0.08 mg/ml is specifically designed and approved for adults weighing over 50 kg. Paediatric dosing of norepinephrine requires different concentrations and specialised protocols that are beyond the scope of this formulation's approved indication.

Sodium Content

Each 50 ml vial of Noradrenalin Aguettant contains 177.3 mg of sodium (the main component of table salt). This is equivalent to approximately 8.9% of the maximum recommended daily sodium intake for adults. Clinicians managing patients on sodium-restricted diets or those with conditions sensitive to sodium load (such as heart failure or renal impairment) should factor this into the patient's total sodium intake calculations.

How Does Noradrenalin Aguettant Interact with Other Drugs?

Norepinephrine has clinically significant interactions with several drug classes, including halogenated anesthetics, certain antidepressants (tricyclics, SNRIs, MAO inhibitors), linezolid, and methylene blue. These interactions can result in dangerous potentiation of blood pressure effects or increased risk of cardiac arrhythmias.

Drug interactions with norepinephrine are particularly important because the consequences can be immediately life-threatening. The vasopressor and cardiac effects of norepinephrine can be dramatically amplified by drugs that inhibit its metabolism or enhance adrenergic signalling. Clinicians must perform a thorough medication reconciliation before initiating norepinephrine therapy and remain vigilant for interactions throughout treatment.

Known Drug Interactions with Norepinephrine
Interacting Drug Interaction Type Clinical Effect Severity
Halogenated anesthetics (halothane, sevoflurane, desflurane) Pharmacodynamic Increased risk of ventricular arrhythmias. Halogenated agents sensitize the myocardium to catecholamines. Major
Tricyclic antidepressants (imipramine, amitriptyline) Pharmacokinetic Potentiated pressor response. TCAs block norepinephrine reuptake, prolonging and intensifying its effects. Major
SNRIs (venlafaxine, duloxetine) Pharmacokinetic Enhanced vasopressor effect through inhibition of norepinephrine reuptake, risking severe hypertension. Major
MAO inhibitors (moclobemide, phenelzine) Pharmacokinetic Dramatically enhanced and prolonged pressor effect. MAOIs prevent norepinephrine breakdown, risking hypertensive crisis. Major
Linezolid (antibiotic) Pharmacokinetic Linezolid has weak MAO-inhibiting properties, potentially enhancing norepinephrine's pressor effects. Moderate
Methylene blue (antidote) Pharmacokinetic Methylene blue inhibits MAO, potentially increasing norepinephrine levels and pressor response. Moderate

Major Interactions

The most dangerous interactions involve drugs that significantly potentiate norepinephrine's cardiovascular effects. Halogenated anesthetics are of particular concern in the operating room setting. These agents sensitize the myocardium to the arrhythmogenic effects of catecholamines, meaning that standard doses of norepinephrine can provoke life-threatening ventricular arrhythmias in patients under halogenated anesthesia. Reduced norepinephrine doses and enhanced cardiac monitoring are essential in this setting.

MAO inhibitors represent another critical interaction. Monoamine oxidase is one of the primary enzymes responsible for breaking down norepinephrine. When this enzyme is inhibited, endogenous and exogenous norepinephrine accumulates, potentially causing hypertensive crisis with blood pressure elevations that can lead to stroke, aortic dissection, or myocardial infarction. Patients on MAO inhibitors (including the reversible inhibitor moclobemide) require significantly reduced norepinephrine doses and meticulous blood pressure monitoring.

Tricyclic antidepressants and SNRIs both inhibit the reuptake of norepinephrine at sympathetic nerve terminals. This is the primary mechanism by which norepinephrine is cleared from the synaptic cleft. When reuptake is blocked, the pressor effect of exogenous norepinephrine is dramatically enhanced and prolonged, necessitating careful dose adjustment and close hemodynamic monitoring.

Moderate Interactions

Linezolid, an oxazolidinone antibiotic commonly used in ICU patients with resistant gram-positive infections, has weak but clinically relevant MAO-inhibiting properties. While the interaction is less severe than with dedicated MAO inhibitors, it can still enhance norepinephrine's pressor effects. Clinicians should be aware of this interaction, particularly since both drugs are frequently used in critically ill patients.

Methylene blue, used as an antidote for methemoglobinemia and increasingly as a rescue therapy in refractory vasodilatory shock, also inhibits monoamine oxidase. When used concomitantly with norepinephrine, it can potentiate the pressor response. However, in clinical practice, these drugs are often used together intentionally in refractory shock, with careful dose titration.

What Is the Correct Dosage of Noradrenalin Aguettant?

Noradrenalin Aguettant is administered as a continuous intravenous infusion through a central venous catheter only. The initial dose is typically 0.05-0.15 micrograms/kg/min, titrated to a maintenance dose of 0.05-1.5 micrograms/kg/min. The 0.08 mg/ml formulation is ready-to-use without dilution.

Dosing of norepinephrine is highly individualized and depends on the patient's hemodynamic response, underlying condition, and concurrent therapies. The goal is to achieve and maintain a target mean arterial pressure (MAP) of at least 65 mmHg, or a low-normal systolic blood pressure of 100-120 mmHg, depending on the clinical context and the patient's baseline. All dose adjustments must be guided by continuous blood pressure monitoring.

Adults (Over 50 kg)

Initial Dose

The starting dose is typically 0.05-0.15 micrograms/kg/min. The infusion is initiated at the lower end of this range and titrated upward based on the observed blood pressure response. The 0.08 mg/ml ready-to-use solution should be infused using an infusion pump or syringe pump for precise rate control.

Maintenance Dose

The recommended maintenance dose range is 0.05-1.5 micrograms/kg/min. Once a stable target blood pressure is achieved, the dose should be maintained at the lowest effective rate. Higher doses may be required in patients with refractory shock, but doses exceeding 1 microgram/kg/min should prompt reassessment of the underlying cause of hypotension and consideration of adjunctive vasopressor therapy.

Dose Titration

Once the infusion is established, the dose should be titrated in increments of 0.05-0.1 micrograms/kg/min based on the observed pressor effect. Each dose adjustment should be followed by a brief observation period (typically 5-10 minutes) to assess the hemodynamic response before making further changes. Rapid dose escalation should be avoided when clinically feasible.

Norepinephrine Dosage Summary
Phase Dose Range Target Notes
Initial dose 0.05-0.15 mcg/kg/min MAP ≥ 65 mmHg Start low, titrate based on response
Maintenance 0.05-1.5 mcg/kg/min SBP 100-120 mmHg or MAP ≥ 65 mmHg Use lowest effective dose
Titration increments 0.05-0.1 mcg/kg/min per step Gradual adjustment Allow 5-10 min between adjustments
Weaning Gradual reduction Hemodynamic stability Never stop abruptly; taper gradually

Children

Noradrenalin Aguettant is intended for adults only. This formulation is not approved for use in paediatric patients. While norepinephrine is used off-label in paediatric critical care, specific paediatric formulations, dosing protocols, and dilution calculations are required. Paediatric intensivists follow separate evidence-based guidelines for vasopressor use in children.

Elderly Patients

No specific dose adjustment is recommended for elderly patients based on age alone. However, older adults often have reduced cardiovascular reserve, increased sensitivity to vasoactive medications, and a higher prevalence of comorbid conditions (atherosclerosis, coronary artery disease, renal impairment). Clinicians typically initiate therapy at the lower end of the dosing range and titrate more cautiously in elderly patients, with particular attention to signs of myocardial ischemia and peripheral vasoconstriction.

Overdose

Overdose with norepinephrine manifests as an exaggeration of its pharmacological effects. Signs and symptoms include:

  • Severe hypertension: Dangerously elevated blood pressure that can lead to stroke, intracranial hemorrhage, or aortic dissection
  • Cutaneous vasoconstriction: Pronounced pallor, cold extremities, and mottled skin due to excessive peripheral vasoconstriction
  • Pressure necrosis: Skin ulceration resulting from prolonged severe vasoconstriction
  • Reflex bradycardia: Significantly slow heart rate as a baroreceptor-mediated response to severe hypertension
  • Circulatory shock: Paradoxical circulatory failure due to excessive afterload and reduced cardiac output

Management of overdose involves immediate dose reduction or discontinuation, with supportive care including blood pressure monitoring and, if necessary, short-acting alpha-adrenergic blocking agents such as phentolamine to reverse the vasoconstrictive effects. The short half-life of norepinephrine (approximately 2-3 minutes) means that effects typically resolve rapidly after dose reduction.

What Are the Side Effects of Noradrenalin Aguettant?

Like all medicines, norepinephrine can cause side effects, though not everyone will experience them. The most commonly reported side effects include anxiety, headache, tremor, tachycardia (rapid heart rate), bradycardia (slow heart rate), and hypertension. Serious side effects include cardiac arrhythmias, acute heart failure, and tissue necrosis at the injection site.

Side effects of norepinephrine are generally dose-dependent and related to its pharmacological mechanism of action. Many of the reported adverse effects represent an exaggeration of the drug's intended vasoconstrictive and cardiac stimulant properties. Close hemodynamic monitoring allows for early detection and dose adjustment to minimize adverse effects while maintaining therapeutic benefit.

Cardiovascular Effects

Reported frequency not precisely established
  • Tachycardia (rapid heart rate)
  • Bradycardia (slow heart rate)
  • Cardiac arrhythmias (irregular heartbeat)
  • Palpitations
  • Increased myocardial contractility
  • Arterial hypertension (high blood pressure)
  • Acute heart failure

Peripheral Vascular Effects

Related to vasoconstriction mechanism
  • Cold and pale extremities and face
  • Painful and cold hands/feet
  • Tissue hypoxia (reduced oxygen supply to organs)
  • Peripheral gangrene (with prolonged use)

Neurological and Psychological

Central nervous system effects
  • Anxiety
  • Headache
  • Tremor

Ocular

Eye-related effects
  • Acute glaucoma (increased intraocular pressure)

Respiratory

Breathing-related effects
  • Difficulty breathing
  • Dyspnoea (shortness of breath)

Gastrointestinal and Urinary

Organ-related effects
  • Vomiting
  • Urinary retention (difficulty emptying the bladder)

Local Effects (Injection Site)

At the infusion site
  • Local irritation
  • Tissue necrosis (cell death at the injection site from extravasation)

Effects of Prolonged Administration

Continuous administration of norepinephrine to maintain blood pressure without adequate fluid volume replacement can lead to a cascade of detrimental effects. These include:

  • Severe peripheral and visceral vasoconstriction: Excessive narrowing of blood vessels in the extremities and internal organs
  • Reduced renal blood flow: Diminished perfusion to the kidneys, potentially leading to acute kidney injury
  • Decreased urine output: Oliguria resulting from reduced renal perfusion
  • Tissue hypoxia: Insufficient oxygen delivery to tissues throughout the body
  • Elevated serum lactate: A marker of anaerobic metabolism indicating inadequate tissue perfusion, associated with worse clinical outcomes

Hypersensitivity and Overdose-Related Effects

In patients with hypersensitivity to norepinephrine or in cases of overdose, additional symptoms may occur more frequently, including severe arterial hypertension, photophobia (abnormal light sensitivity), retrosternal pain (chest pain behind the breastbone), pharyngeal pain (sore throat), pronounced pallor, intense sweating, and vomiting. These symptoms require immediate dose reduction and appropriate supportive care.

Reporting side effects:

If you or someone you know experiences side effects from norepinephrine, these should be reported to the treating medical team immediately. Healthcare professionals can also report suspected adverse reactions to their national pharmacovigilance agency (e.g., the FDA MedWatch program in the United States, the MHRA Yellow Card scheme in the United Kingdom, or the EMA EudraVigilance system in the European Union).

How Should You Store Noradrenalin Aguettant?

Store Noradrenalin Aguettant at or below 25°C (77°F), protected from light in the original carton. Use immediately after first opening. Do not use if the solution appears darker than slightly yellow or pink, or if it contains particles.

Proper storage of norepinephrine is critical to maintaining its potency and safety. Norepinephrine is chemically unstable and can undergo oxidative degradation when exposed to light, heat, or alkaline conditions. The degradation products may be ineffective or potentially harmful, making adherence to storage conditions essential.

  • Temperature: Store at or below 25°C (77°F). Do not freeze. Avoid exposure to excessive heat.
  • Light protection: Keep the vials in the original outer carton to protect from light. Norepinephrine is photosensitive and will degrade more rapidly when exposed to light.
  • After opening: The product must be used immediately after first opening the vial. Any unused solution should be discarded. Do not store opened vials for later use.
  • Expiry date: Do not use after the expiry date printed on the vial label and carton (EXP). The expiry date refers to the last day of the stated month.
  • Visual inspection: Before use, visually inspect the solution. Do not use if the solution is darker than slightly yellowish or has a pink discoloration, or if it contains visible particles or precipitates.
  • Keep out of reach of children: As with all medications, store out of the sight and reach of children, although this medication is used exclusively in hospital settings.

Unused medication and waste should be disposed of in accordance with local institutional guidelines and environmental regulations. Norepinephrine should not be disposed of via household waste or wastewater systems.

What Does Noradrenalin Aguettant Contain?

Each ml of Noradrenalin Aguettant 0.08 mg/ml solution contains 0.08 mg norepinephrine (as norepinephrine tartrate). Each 50 ml vial contains 4 mg norepinephrine total. The solution also contains sodium chloride, disodium edetate, and water for injections.

Active Ingredient

The active substance is norepinephrine, present as norepinephrine tartrate. Each millilitre of the solution contains 0.08 mg of norepinephrine base (equivalent to approximately 0.16 mg norepinephrine tartrate). Each 50 ml glass vial therefore contains a total of 4 mg norepinephrine.

Excipients (Inactive Ingredients)

  • Sodium chloride: Used as a tonicity agent to make the solution isotonic with blood
  • Disodium edetate (EDTA): Used as a stabilizer and chelating agent to prevent metal-catalysed oxidative degradation of norepinephrine
  • Hydrochloric acid or sodium hydroxide: Used for pH adjustment to ensure stability and compatibility
  • Water for injections: Pharmaceutical-grade water serving as the solvent

Physical Appearance

Noradrenalin Aguettant is a clear, colourless to slightly yellowish solution for infusion, presented in a clear glass vial. Each vial contains 50 ml of solution. The product is available in pack sizes of 1, 10, and 25 vials, although not all pack sizes may be marketed in every country.

The product is manufactured by Laboratoire Aguettant, located at 1, rue Alexander Fleming, 69007 Lyon, France. It is supplied as a ready-to-use formulation that does not require dilution before administration. The solution must not be mixed with any other medicinal products. It is intended for single use only; any unused portion must be discarded.

Frequently Asked Questions

Noradrenalin Aguettant is used for the emergency treatment of acute hypotension (dangerously low blood pressure) in adults weighing over 50 kg. It is the first-line vasopressor recommended by international critical care guidelines (Surviving Sepsis Campaign 2021) for septic shock. The medication works by constricting blood vessels to raise blood pressure. It is used exclusively in hospital settings, typically in intensive care units, where continuous hemodynamic monitoring is available.

Norepinephrine must be administered as a continuous intravenous infusion through a central venous catheter. It must never be given through a peripheral IV line, as extravasation (leakage into surrounding tissue) can cause severe tissue necrosis. The infusion rate is controlled precisely using an infusion pump or syringe pump. The 0.08 mg/ml formulation is supplied ready-to-use without dilution, while the 1 mg/ml concentrate requires dilution before use.

Norepinephrine (noradrenaline) and epinephrine (adrenaline) are both catecholamines but act differently on adrenergic receptors. Norepinephrine primarily stimulates alpha-1 receptors causing vasoconstriction with moderate beta-1 cardiac stimulation, making it ideal for raising blood pressure in septic shock. Epinephrine acts more equally on both alpha and beta receptors, producing stronger heart rate and contractility increases, making it the drug of choice for anaphylaxis and cardiac arrest. Norepinephrine causes less tachycardia (rapid heart rate) than epinephrine.

The most frequently reported side effects of norepinephrine include cardiovascular effects such as tachycardia (rapid heart rate), bradycardia (slow heart rate), cardiac arrhythmias, and hypertension. Peripheral vascular effects are also common, including cold and pale extremities, reduced blood flow to fingers and toes, and tissue hypoxia. Neurological effects such as anxiety, headache, and tremor may also occur. Most side effects are dose-dependent and can be managed by dose adjustment.

No, norepinephrine must never be stopped abruptly. Sudden discontinuation can cause acute, life-threatening hypotension (a dangerous drop in blood pressure). The infusion must always be tapered gradually, with dose reductions made in small increments while monitoring blood pressure closely. When the patient is ready for weaning, the dose is progressively reduced until hemodynamic stability is maintained without vasopressor support. The treating team will determine the appropriate weaning protocol based on the patient's clinical condition.

Norepinephrine must be given through a central venous catheter because of the severe risk of tissue damage if the drug leaks out of a peripheral vein (extravasation). Norepinephrine causes intense vasoconstriction, and if it escapes into the surrounding tissue, it can cut off blood supply to the skin and underlying structures, leading to tissue ischemia, necrosis (tissue death), and potentially requiring surgical intervention or amputation. Central venous catheters have larger veins with higher blood flow, which dilutes the drug more effectively and minimizes the risk of local tissue damage.

References

  1. Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Intensive Care Medicine. 2021;47(11):1181-1247. doi:10.1007/s00134-021-06506-y
  2. European Medicines Agency (EMA). Summary of Product Characteristics: Norepinephrine. EMA product database. Accessed 2025.
  3. Overgaard CB, Dzavik V. Inotropes and vasopressors: review of physiology and clinical use in cardiovascular disease. Circulation. 2008;118(10):1047-1056. doi:10.1161/CIRCULATIONAHA.107.728840
  4. De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of shock. New England Journal of Medicine. 2010;362(9):779-789. doi:10.1056/NEJMoa0907118
  5. World Health Organization (WHO). WHO Model List of Essential Medicines - 23rd List, 2023. Geneva: World Health Organization; 2023.
  6. British National Formulary (BNF). Norepinephrine/Noradrenaline. NICE Evidence Services. Updated 2025.
  7. Annane D, Ouanes-Besbes L, de Backer D, et al. A global perspective on vasoactive agents in shock. Intensive Care Medicine. 2018;44(6):833-846. doi:10.1007/s00134-018-5242-5
  8. Laboratoire Aguettant. Noradrenalin Aguettant 0.08 mg/ml, solution for infusion - Summary of Product Characteristics. Last updated November 2022.

About Our Medical Editorial Team

This article was written and reviewed by iMedic's Medical Editorial Team, comprising board-certified physicians with expertise in critical care medicine, clinical pharmacology, and emergency medicine. Our content follows the GRADE evidence framework and adheres to the highest standards of medical accuracy.

Evidence-Based Content

All information is based on peer-reviewed research, international guidelines (SSC, EMA, WHO, BNF), and expert clinical consensus.

Independent & Unbiased

iMedic receives no commercial funding or pharmaceutical sponsorship. Our editorial independence ensures unbiased medical information.

Regular Updates

Content is reviewed and updated regularly to reflect the latest medical evidence, guideline changes, and safety information.

Accessible to All

Our content meets WCAG 2.2 AAA accessibility standards, ensuring medical information is available to everyone regardless of ability.