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Noradrenaline Guideline
1 vial = 4mg Noradrenaline Acid Tartrate/2mL = 2mg Noradrenaline (base)/ 2mL
NB: all doses referred to in this document are stated as the base.
Indications:
• For the restoration of blood pressure in certain acute hypotensive states (e.g. myocardial
infarction, septicaemia, drug reactions, poliomyelitis, spinal anaesthesia)
• As an adjunct in the treatment of cardiac arrest – to restore and maintain an adequate blood
pressure after an effective heartbeat and ventilation have been established by other means.
Dose:
Usual initial dose is 8 to 12 micrograms per minute.
Dose requirements are highly variable and need to be adjusted according to patient response.
The average maintenance dose ranges from 2 to 8 micrograms per minute.
Adjust the rate of flow to establish and maintain an adequate blood pressure (usually 80-100mmHg
systolic) sufficient to maintain circulation to vital organs. In previously hypertensive patients, it is
recommended that the blood pressure should be raised no higher than 40mmHg below the preexisting systolic pressure.
Administration:
• Add 4mg noradrenaline (base) to 46mLs of a compatible solution in a 60 mL syringe.
= 2 x2mL vials LEVOPHED1:1000 amps
This produces an 80 microgram/mL solution of noradrenaline.
o
•
Administration should be given via a syringe driver as an intravenous infusion via a central
line.
•
Compatible fluids: 5% dextrose; sodium chloride 0.9% and dextrose 5%;
o The use of dextrose-containing solutions as diluents provides protection from
oxidation and subsequent loss of potency.
DOSE
(micrograms/min)
1
2
3
4
5
6
7
8
9
10
11
12
RATE
(mLs/hour)
0.75
1.5
2.25
3
3.75
4.5
5.25
6
6.75
7.5
8.25
9
Noradrenaline Guideline
Document Owner: Medication Safety Committee
WCDHB-MED#28 Version 2, Revised: May 2017
Page 1 of 3
Master Copy is Electronic
Noradrenaline Guideline
Noradrenaline has a short duration of action, and its actions will cease within 1-2 minutes after the
infusion is discontinued. Reduce infusion gradually, avoid abrupt withdrawal.
Observation and Monitoring:
• Continuous cardiovascular monitoring, including BP and heart rate
• Signs of overdose: headache, severe hypertension, reflex bradycardia, marked increase in
peripheral resistance and decreased cardiac output.
Mechanism of action:
Noradrenaline is a peripheral vasoconstrictor (α-adrenergic action). It also acts at β-adrenergic
receptors producing inotropic stimulation to the heart and dilation of coronary arteries. The sum of
these actions results in an increase in systemic blood pressure and coronary artery blood flow.
Contraindications:
• 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 administered.
• Patients with mesenteric or peripheral vascular thrombosis, UNLESS the attending Doctor
deems it a necessary life-saving procedure.
• Hypersensitivity to noradrenaline or any of the formulation components. LEVOPHED
1:1000 contains sodium metabisulfite – avoid in patients with established sulfite
hypersensitivity.
Precautions:
• Caution in patients receiving monoamine oxidase inhibitors; triptyline or imipramine antidepressants; beta-blockers or clonidine. Severe, prolonged hypertension may result.
• LEVOPHED 1:1000 contains sodium metabisulfite which may cause allergic-type reactions
including anaphylaxis or asthmatic episodes in susceptible people.
• Noradrenaline should be given via a central line due to the risk of necrosis of the overlying
skin from prolonged vasoconstriction.
• Care needs to be taken to avoid extravasation of noradrenaline into the tissues, as local
necrosis may occur due to its vasoconstrictive actions. The antidote for extravasation is
phentolamine (an adrenergic blocking agent). The area should be infiltrated as soon as
possible with 10 to 15mL of saline solution containing 5 to 10mg of phentolamine. A
syringe with a fine hypodermic needle should be used to infiltrate the area liberally with the
prepared solution. This will cause immediate and conspicuous local hyperaemic changes if
the area is infiltrated within 12 hours.
• Pregnancy: Avoid if possible – may reduce placental perfusion.
• Breast-feeding: Limited data, use only if clear clinical indication.
Possible adverse effects:
• Arrhythmias
• Bradycardia
• Peripheral (digital) ischemia
Noradrenaline Guideline
Document Owner: Medication Safety Committee
WCDHB-MED#28 Version 2, Revised: May 2017
Page 2 of 3
Master Copy is Electronic
Noradrenaline Guideline
•
•
•
Anxiety
Headache (transient)
Skin necrosis (with extravasation)
Drug interactions:
Medications
Monoamine Oxidase
Inhibitors
Interaction
The pressor effects of noradrenaline may be moderately increased. The
increase may be greater in those who show a significant hypotensive
response to the MAOI.
The pressor effects of noradrenaline may be increased.
Tricyclic Antidepressants
Ergot derivatives
The pressor effects of noradrenaline may be increased.
Beta-blockers
The pressor effects of noradrenaline may be reduced.
Serotonin/noradrenaline The pressor effects of noradrenaline may be increased.
reuptake inhibitors
Storage:
Store below 25oC. Do not freeze. Protect from light. Single use ampoules, discard remaining
solution.
Noradrenaline solution is adversely affected by light and air. Solutions that are discoloured (pink or
brown) or contain precipitate should not be used.
List of excipients:
Sodium metabisulfite 2 mg/mL as an antioxidant, sodium chloride 8 mg/mL for tonicity, and water
for injections.
References:
References
1
2
3
4
5
6
Title/Description
Noradrenaline profile New Zealand Formulary. Available from www.nzf.org.nz 10/6/2014
Notes on Injectable Drugs 6th Ed. 2010
Drug Information Handbook 21st Ed. (2012-2013) Lexicomp
LEVOPHED 1:1000 Datasheet. Available from www.medsafe.govt.nz Accessed
25/08/2014
Drugs in Pregnancy and Lactation 8th Ed. Briggs, G. Freeman, R. Yaffe S
Stockleys Drug Interactions 7th Ed. Pharmaceutical Press
Noradrenaline Guideline
Document Owner: Medication Safety Committee
WCDHB-MED#28 Version 2, Revised: May 2017
Page 3 of 3
Master Copy is Electronic
Noradrenaline Guideline
Noradrenaline Guideline
Document Owner: Medication Safety Committee
WCDHB-MED#28 Version 2, Revised: May 2017
Page 4 of 3
Master Copy is Electronic