Noradrenaline (Norepinephrine): Uses and Safety

What is noradrenaline (norepinephrine)?

Noradrenaline and norepinephrine are two names for the same active substance. It is a catecholamine with predominantly alpha-adrenergic vasoconstrictor activity and some beta-adrenergic cardiac activity.

Vasoconstriction raises peripheral vascular resistance and blood pressure. The haemodynamic response can also include reflex slowing of the heart rate, and cardiac output may not always increase.

What is noradrenaline injection used for?

The exact authorised wording is product- and country-specific. Current UK product information for a 1 mg/mL concentrate indicates noradrenaline as an emergency measure to restore blood pressure in acute hypotension. Current US labelling similarly describes norepinephrine bitartrate injection for raising blood pressure in adults with severe acute hypotension.

Clinical teams may use noradrenaline in several causes of circulatory shock, but labels do not necessarily list “septic shock” or “cardiogenic shock” as separate universal indications. Diagnosis, correction of the underlying cause and haemodynamic targets belong to the treating critical-care team.

What does 1 mg/mL mean?

The strength must be read together with the product name and composition. In the current UK SmPC reviewed for this article, each millilitre contains 2 mg noradrenaline tartrate, equivalent to 1 mg noradrenaline base. A current US label likewise expresses 1 mg/mL as norepinephrine base supplied as the bitartrate salt.

One milligram per millilitre is the concentrate strength, not a universal final infusion concentration. The concentrate requires dilution before infusion. Ready-to-use norepinephrine bags also exist at much lower concentrations, so products must not be interchanged on the basis of the drug name alone.

How is it administered?

Noradrenaline is administered as a controlled intravenous infusion. The UK product reviewed specifies dilution, administration through a central venous catheter and delivery with a pump or other controlled-rate device. US labels may describe administration into a large vein and provide different product-specific dilution instructions.

• Confirm whether the container is a concentrate or ready-to-use solution.
• Confirm whether strength is expressed as noradrenaline/norepinephrine base or as a salt.
• Use only the diluent and final concentration permitted by the exact product information and local protocol.
• Titrate to the prescribed haemodynamic target with frequent blood-pressure assessment.
• Reduce the infusion gradually when stopping it; abrupt cessation can cause marked hypotension.

This page deliberately does not provide a standalone mixing recipe or bedside dose table because applying instructions from the wrong product or jurisdiction can cause a serious medication error.

Blood volume, monitoring and infusion-site safety

Official UK and US information stresses assessment and correction of hypovolaemia. Giving noradrenaline in inadequately corrected volume depletion can produce intense vasoconstriction while organ and tissue perfusion remain poor.

Monitoring normally includes blood pressure, heart rhythm, response to treatment, peripheral and organ perfusion, urine output and the infusion site. Exact monitoring frequency is determined by the product information and critical-care protocol.

Extravasation can cause local ischaemia and tissue necrosis. The infusion site must be checked frequently and suspected extravasation treated immediately under the institution’s emergency protocol. Central venous administration may reduce peripheral extravasation risk, but line placement and urgency must be assessed clinically.

Adverse effects and important precautions

Important adverse effects in official product information include:

• hypertension and reflex bradycardia;
• cardiac arrhythmias;
• peripheral or visceral ischaemia, including reduced renal perfusion;
• extravasation necrosis;
• headache, anxiety or breathing difficulty; and
• marked hypotension if the infusion is stopped abruptly.

Caution is particularly important in people with coronary, mesenteric or peripheral vascular disease, myocardial ischaemia, hypoxia or hypercarbia. The UK SmPC also lists hypertension, diabetes and hyperthyroidism among conditions requiring particular caution.

Contraindications are not universal

The previous version of this page listed severe hypertension and hyperthyroidism as contraindications. That classification was not supported by the current labels reviewed and has been corrected.

The current UK product reviewed lists hypersensitivity to noradrenaline tartrate or an excipient as its contraindication and treats hypertension and hyperthyroidism as cautions. The current US label reviewed lists no formal contraindications. This difference demonstrates why the exact product and jurisdiction must be checked rather than using a generic list.

Drug interactions

Official information warns that monoamine oxidase inhibitors, medicines with MAO-inhibiting properties such as linezolid, tricyclic antidepressants and certain other sensitising medicines can produce severe or prolonged hypertension. Some volatile halogenated anaesthetics can increase the risk of serious ventricular arrhythmias.

These interactions are managed in a monitored clinical environment. Noradrenaline should not be confused with lidocaine with adrenaline, a different medicine combination used for local anaesthesia.

Pregnancy, breastfeeding and children

Recommendations depend on the product and clinical emergency. The UK SmPC notes potential effects on placental perfusion and the fetal heart rate and says that fetal risk must be weighed against maternal benefit. The US label emphasises that life-sustaining therapy for severe maternal hypotension should not be withheld solely because of fetal concerns.

The UK product reviewed is not recommended for the paediatric population, while the US label states that safety and effectiveness in paediatric patients have not been established. Neither statement should be applied to a different product without checking its label.

Frequently asked questions

Official sources

The medical information above was checked against current UK and US product information. It is not a substitute for the exact label or a hospital protocol.

• UK SmPC: Noradrenaline (Norepinephrine) 1 mg/mL Concentrate for Solution for Infusion
• US DailyMed: Norepinephrine Bitartrate Injection official label