Norepinephrine vs Epinephrine in Post-Cardiac Arrest Shock

• The effects of epinephrine on animal hemodynamics have been studied since the late 1800s with

recent concern with deleterious complications with cerebral and myocardial oxygen supply.

• Recently, there has been consideration for norepinephrine post cardiac arrest to minimize the

complications associated with epinephrine

Epinephrine

Norepinephrine

Dose

Weight-based dosing:

● Usual dosage range: 0.01 to 1

mcg/kg/minute; titrate based on

clinical end points (eg, MAP, end-

organ perfusion)

Non-weight-based dosing:

● Usual dosage range: 1 to 80

mcg/minute; titrate based on

clinical end points (eg, MAP, end-

organ perfusion

Institutional infusion rates may vary

Weight-based dosing:

● Initial: 0.05 to 0.15 mcg/kg/minute; titrate

based on clinical end points (eg, MAP, end-

organ perfusion); usual dosing range: 0.05 to

1 mcg/kg/minute

Non-weight-based dosing (based on ~80 kg

patient):

● Initial: 5 to 15 mcg/minute; titrate based on

clinical end points (eg, MAP, end-organ

perfusion); usual dosing range: 5 to 80

Onset: Immediate

Distribution: 1-2 minutes to reach

peak

Metabolism: rapid hepatic

degradation

Elimination: urine (inactive

metabolites)

Half-life: <5 minutes

Onset: Immediate

Distribution: 1-2 minutes to reach peak

Metabolism: rapid hepatic degradation

Elimination: urine (inactive metabolites)

Half-life: <5 minutes

Adverse Effects Tachyarrhythmias, myocardial ischemia, extravasation leading to necrosis,

7/30/2025

Mechanism of Action

Receptor Activity

Pharmacological Action

Effect

α agonist

Peripheral vasoconstriction increased myocardial and cerebral blood flow

β agonist

increased heart rate and contractility increased myocardial oxygen demand

Author (Year)

Study

Design/Patient

Population

Intervention

Results

Bougouin, 2022

Retrospective

N=766

● Norepinephrine infusion

● Epinephrine infusion

●

All-cause hospital mortality was

significantly higher in the

epinephrine group (OR 2.6; 95%CI

• 4-4.7; P = 0.002).

●

Proportion of patients with CPC of 3-5

at hospital discharge was also higher

with epinephrine

Weiss,

2021

Retrospective

N=93

●

Norepinephrine infusion

●

Epinephrine infusion

●

Significantly more EPI patients had

refractory hypotension, rearrest, or

death in the emergency department

(EPI 21/42, 50% vs. NE 10/45, 22.2%;

P = 0.008)

●

In an adjusted regression model, the

odds of reaching the primary outcome

in the ED were 3.94 [95%CI 1.38-12.2]

(P = 0.013) times higher in the EPI

group compared to NE treated patients.

Mion, 2014

Case

● It’s controversial as to whether epinephrine is preferred vasopressor post cardiac arrest.

● Norepinephrine is a reasonable agent to use post arrest if it is clinically warranted.

7/30/2025

● Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Accessed 2022,

March 15.

● http://www.micromedexsolutions.com/

● Callaway C. Epinephrine for cardiac arrest. Current Opinion in Cardiology. 2013;28(1):36-42.

● Epinephrine [package insert] Lake Forest, IL: Hospira, Inc.; 2019.

● (poster) Kim et al. THE BENEFIT OF NOREPINEPHRINE INFUSION FOR HEMODYNAMIC

SUPPORT FOLLOWING CARDIOPULMONARY ARREST AND RESUSCITATION. Critical Care

Medicine: December 2012 – Volume 40 – Issue 12 – p 1-328

● Mion Get al. Cardiac arrest: should we consider norepinephrine instead of epinephrine? Am J

Emerg Med. 2014 Dec;32(12):1560.e1-2. PMID: 24997106.

● Weiss A, et ql. Comparison of Clinical Outcomes with Initial Norepinephrine or Epinephrine for

Hemodynamic Support After Return of Spontaneous Circulation. Shock. 2021 Dec 1;56(6):988-993.

PMID: 34172611.

● Bougouin W, et al. Epinephrine versus norepinephrine in cardiac arrest patients with post-

resuscitation shock. Intensive Care Med. 2022 Mar;48(3):300-310. PMID: 35129643.