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Drug dosage identifier

Noradrenaline

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Dose and administration

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  • 50-500 nanograms/kg/min (0.05-0.5 micrograms/kg/minute) by continuous IV infusion via a central venous catheter.
  • Dose is guideline only and must be considered in light of clinical response. Begin at low dose and titrate to effect. Dosages should be increased or decreased in small increments only.
  • Administer via a central line (UVC, Longline, or Surgical CVL).
  • Usual dilution 300 micrograms/kg (0.3 ml/kg) noradrenaline to make 50 ml with D5W.
  • 50 nanograms/kg/min (0.05 micrograms/kg/minute) = 0.5 ml/hour .
  • Noradrenaline (mcg) in 50ml IV Solution = 3 x weight (kg) x dose (nanograms/kg/min)
                                                                                     IV Rate (ml/hr)

Indication

  • Blood pressure support in infants who are not responsive to high dose dopamine (i.e. (15-20 micrograms/kg/minute).
  • Must discuss with the specialist on duty before instituting this treatment.

Contraindications

  • Uncorrected hypovolaemia is an absolute contraindication.
  • Hypertension.
  • Mesenteric or peripheral vascular thrombosis2.

Precautions

  • Hypoxia or hypercapnia (may cause noradrenaline-induced cardiac arrhythmias).

Drug interactions

  • Halogenated anaesthetic agents: serious cardiac arrhythmias may occur with concomitant use4.
  • Digoxin: increased risk of arrhythmias4.
  • Beta blockers: risk of hypertension4.
  • Doxapram: risk of hypertension4.

Clinical pharmacology

Noradrenaline is a catecholamine agent with β-1 and potent α-1 activity. It acts primarily to raise systemic vascular resistance and therefore blood pressure. It also has a direct stimulatory action on the myocardium. However, this may be overshadowed by reflex decreases in cardiac output occasionally manifested by a reduction in heart rate. Marked bradycardia would be unusual (adults) and indeed heart rate may increase. There is virtually no published data on the haemodynamic effects in the neonatal age group. There is no evidence of a beneficial effect on the ratio of pulmonary vascular resistance/systemic vascular resistance in persistent pulmonary hypertension of the newborn. The drug must be given by continuous infusion. It is rapidly metabolised and has a half-life of less than 5 minutes.

Possible adverse effects

  • Extravasation can cause profound local vasoconstriction and tissue necrosis. If extravasation occurs infiltrate with 5 mg phentolamine mesylate in 10 ml sodium chloride 0.9% using a fine neeedle4.
  • May cause large increases in blood pressure. Rapid changes in blood pressure should be avoided.
  • Plasma volume depletion4.
  • Arrhythmias, bradycardia. Severe arrhythmias warrant discontinuation of the drug.
  • Peripheral ischaemia including gangrene of the extremities4.
  • Contains sodium metabisulphite as preservative. This agent can cause hypersensitivity reactions including anaphylactic symptoms2.

Special considerations

  • Ensure patient is not hypovolaemic. Correct if necessary before commencing therapy.
  • Administer via a central venous catheter.
  • Clinical experience with noradrenaline is extremely limited and clinical efficacy and potential problems are not clearly defined. It is therefore not appropriate as a first line treatment and should be reserved for intractable hypotension not responsive to volume loading or high dose dopamine.
  • Safety and efficacy of noradrenaline in paediatric patients has not been established2.

Management of Noradrenaline administration

Description

  • Clear colourless solution containing noradrenaline base 1 mg/ml (=1000 micrograms/ml) (contains sodium metabisulphite as an antioxidant).
  • Stable in solutions of pH 3.6 - 6.0 4.

Prescription

Charted on fluid chart giving:

  • rate in ml/hour
  • dose in nanograms/kg/minute

Also charted on drug chart under continuous infusions giving:

  • amount of drug to be added
  • base fluid type and volume
  • nanograms/kg/ml

Administration

Continuous Infusion:

  • Administered by a nurse with Neonatal IV Drug Certification.
  • Administered through a Pall 0.2 micron filter into a central venous catheter, except in exceptional circumstances where a large vein can be used e.g. antecubital or femoral vein, in preference to veins of the legs4.
  • Dilute 300 micrograms/kg (0.3ml/kg) noradrenaline to 50 ml with glucose 5% (6 micrograms/kg/ml). Administration in saline solutions alone is not recommended; however glucose 5% in saline can be used2.
  • An infusion rate of 0.5 ml/hour = 0.05 micrograms/kg/minute. Dilution can be varied depending on clinical fluid requirements.
  • Do NOT mix with any other drug, IV solution, blood or blood products. Use a separate line for noradrenaline.
  • Administer via a syringe pump.
  • Change fluid and tubing every 12 hours. Do not use if solution forms a precipitate or if brown discolouration observed.
  • Give through a central venous line (UVC, Longline, or Surgical CVL).

Observation and documentation

  • Monitor infusion rate frequently.
  • Monitor for adverse reactions.
  • Observe solution for brown discolouration or precipitate.
  • Observe closely for extravasation. Discontinue immediately and notify doctor. Noradrenaline must be immediately resited as there is a danger of rebound hypotension.
  • Continuous blood pressure monitoring.
  • Continuous cardio-respiratory monitoring.
  • Document vital signs hourly and PRN.
  • Never cease infusions abruptly, because of the danger of rebound hypotension.

Storage

  • At room temperature 15-25°C.

Selected references

  1. McEvoy GK (ed) AHFS Drug Information 93, American Society of Hospital Pharmacists, Bethesda, 1993; 745-748.
  2. Data sheet. Levophed; November 1999. Sterling Winthrop.
  3. Reynolds JEF (ed.) Martindale: The Extra Pharmacopoeia. (31st ed). London : Royal Pharmaceutical Society, 1996.
  4. Royal College of Paediatrics and Child Health. Medicines for Children. London: RCPCH Publications Ltd, 1999.

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Document Control

  • Date last published: 30 April 2002
  • Document type: Drug Dosage Guideline
  • Services responsible: ADHB Pharmacy, Neonatology
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years