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Paediatric Critical Care Unit Pharmacopoeia Noradrenaline (Norepinephrine) Presentation: Indications: Injection 1 in 1,000 (1mg/mL of Noradrenaline Base), 4 mL ampoules • Persistent hypotension after initial fluid resuscitation. • Shock secondary to excessive vasodilation. N.B All doses Refer to Noradrenaline Base. Dose: Initially 0.02 - 0.1 micrograms/kg/minute, increasing as needed up to a usual maximum of 1 micrograms/kg/minute. Higher rates may occasionally be necessary: this should only be with consultant approval. Route of Administration: Intravenous Infusion, VIA CENTRAL LINE ONLY. Can also be given via the Intraosseus route. Directions for I.V. Administration: Cautions and Contraindications: Common Side Effects: Amount of drug to be added to 50 mL syringe 0.3mg x body weight (kg) 1 mL/hr = Dose range 0.1 0.02 to 1 micrograms/kg/minute micrograms/kg/minute (but see notes above). Concomitant use of digoxin and tricyclic antidepressants increases susceptibility to arrhythmias. Enhanced hypertensive effect if given with tricyclic antidepressants, clonidine and/or beta-blockers. Use with caution in vascular thrombosis (e.g. coronary, mesenteric or peripheral), hyperthyroidism, diabetes mellitus, hypoxia or hypercapnia. Risk of tissue necrosis on extravasation. Acidosis may reduce effectiveness. Hypertension, bradycardia, tachycardia, hypoxia, arrhythmias, nausea, vomitting, tremor, urinary retention, confusion, angle-closure glaucoma and peripheral ischaemia (including gangrene of extremities). Overdose may result in severe hypertension, reflex bradycardia, marked increase in peripheral vascular resistance and decreased cardiac output. Prolonged administration may lead to plasma volume depletion. Compatible Incompatible 4 Compatibility (Y – site): Dilute to 50 mL with either: 5% glucose 10% glucose7 0.9% saline Acetylcysteine 4, 5 Adrenaline 4,6 Atracurium 6 Calcium Chloride 6 Calcium Gluconate 4, 5 Clonidine 4, 5 Dobutamine 4, 5 Dopamine 5 Esmolol 4, 5 Fentanyl 4, 5 Glyceryl trinitrate 4, 5 Heparin 4, 5 Labetalol 4, 5 Midazolam 5 Milrinone 4, 5 Morphine 4, 5 Potassium chloride 5 Propofol 4, 5 Remifentanil 4 Rocuronium Sodium 4, 5 nitroprusside 5 Vasopressin 4 Aminophylline 4, 5 Insulin 6 Sodium Bicarbonate 6 Thiopental Clearance of drug is not affected by renal function. Continuous haemodynamic monitoring should be performed during treatment (unless this is not possible due to technical reasons), and frequent assessment of limb perfusion is also required. Additional Comments: Some preparations contain sodium metabisulphate, which can cause anaphylaxis and severe bronchospasm (more likely in patients with asthma). Discard solution if discoloured or cloudy. 2mg of Noradrenaline Acid Tartrate is Equivalent to 1mg of noradrenaline base. Version 2, May 2015, Review May 2017 Checked: Andrew Wignell, PICU Pharmacist/Amy-Jo Hooley, Paediatric Pharmacist. Approved: PICU Consultants. Paediatric Critical Care Unit Pharmacopoeia References 1. 2. 3. 4. 5. nd Medicines for Children, 2 Edition, 2003. BNF for Children, 2014-2015. th Guy’s and Thomas’ Paediatric Formulary, 9 Edition, 2010. nd University College Hospitals Injectable Medicines Administration Guide, 2 Edition, 2007. Trissel LA (ed), Handbook on Injectable Drugs. [online] London: Pharmaceutical Press accessed via www.medicinescomplete.com (accessed on 09/01/2015). 6. Medusa Injectable Medicines Guide: accessed via http://medusa.wales.nhs.uk/ (accessed on 09/01/2015). th 7. Northern Neonatal Formulary, 6 Edition, 2011. Version 2, May 2015, Review May 2017 Checked: Andrew Wignell, PICU Pharmacist/Amy-Jo Hooley, Paediatric Pharmacist. Approved: PICU Consultants.