Noradrenaline

ADMINISTRATION ROUTES:

IV

ALTERNATIVE NAMES:

Levophed, norepinephrine

ICU INDICATIONS:

1. Septic shock
2. Other distributive shock

PRESENTATION AND ADMINISTRATION:

10 mg in 100 mL (0.1 mg/mL) pre-mixed bags; 2 mg in 2 mL vials (1:1000)

Central or peripheral administration: use the 10 mg in 100 mL (0.1 mg/mL) pre-mixed bags

If central venous access is available, it should be used to administer noradrenaline in preference to a peripheral line.

Evidence shows peripheral noradrenaline is safe when administered appropriately.

When a peripheral line is used for noradrenaline:

• the cannula must not be sited in the antecubital fossa (which will occlude with elbow flexion)
• the line must be well secured
• the line must flush easily
• the infusion must run consistently without intermittent occlusion
• the infusion should not exceed 10 mL/hr

See more details on the "Peripheral Noradrenaline in ICU" policy on District Docs

Central administration only: If required, the 2 mg in 2 mL vials (1:1000) can be used to make up double strength noradrenaline by adding 20 mg of noradrenaline to 100 mL of compatible IV fluid (0.2 mg/mL)

Compatible with the following IV fluids: glucose 5%, glucose 5% with sodium chloride 0.45%

Store at room temperature

DOSAGE:

IV:

0 - 20 mL/hr (higher doses may be required)

DOSAGE IN RENAL FAILURE AND RENAL REPLACEMENT THERAPY:

No dosage adjustment is required

DOSAGE IN PAEDIATRICS:

IV Infusion:

0.3 mg/kg in 50 mL 5% dextrose at 0.5 - 10 mL/hr (equates to 0.05 - 1 mcg/kg/min)

CLINICAL PHARMACOLOGY:

Noradrenaline bitartrate functions as a peripheral vasoconstrictor (alpha-adrenergic action) and as an inotropic stimulator of the heart and dilator of coronary arteries (beta- adrenergic action). The alpha action predominates.

CONTRAINDICATIONS:

Nil

WARNINGS:

Noradrenaline injection contains sodium metabisulfite, a sulfite that may cause allergic-type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people.

Noradrenaline should be used with caution in patients receiving monoamine oxidase inhibitors (MAOIs) or triptyline/imipramine antidepressants as severe prolonged hypertension may result.

Extravasation of noradrenaline is very uncommon. If it occurs, manage as follows:

1. Identify extravasation early e.g. by change in infusion pressure, leakage into tissues with swelling, redness, induration or blanching
2. Stop the infusion and recommence immediately though an alternative access site
3. Inform medical staff
4. Attempt to aspirate extravasated noradrenaline if easy to do so
5. Consider elevation of the limb for 24 hours
6. Observe for signs of complications of extravasation including pain, skin colour change, blistering
7. Consider local vasodilatation by topical application of GTN spray (1 - 5 sprays)

PRECAUTIONS:

General:

Noradrenaline should not be given to patients who are hypotensive from blood volume deficits except as an emergency measure to maintain coronary and cerebral artery perfusion until blood volume replacement therapy can be completed

Laboratory Tests:

No tests additional to routine ICU tests are required

Drug/Laboratory Test Interactions:

None reported

IMPORTANT DRUG INTERACTIONS IN ICU:

None of note

ADVERSE REACTIONS:

Body as a Whole:

Ischaemic injury due to potent vasoconstrictor action tissue hypoxia

Cardiovascular System:

Bradycardia, probably as a reflex result of a rise in blood pressure. Also arrhythmias (including ventricular tachycardia, atrial fibrillation, ventricular fibrillation) which may be exacerbated in the setting of hypoxaemia or hypercarbia

Nervous System:

Anxiety, transient headache