Noradrenaline (as base) parenteral
- Drugs List
- Therapeutic Indications
- Dosage
- Administration
- Contraindications
- Precautions and Warnings
- Pregnancy and Lactation
- Side Effects
- Monograph
Presentation
Parenteral formulations of noradrenaline.
Drugs List
Therapeutic Indications
Uses
Hypotension - acute
Indicated for use as an emergency measure in the restoration of blood pressure in cases of acute hypotension.
Noradrenaline 0.08mg/ml and 0.16mg/ml solutions for infusion are indicated in adults weighing over 50kg for the ongoing treatment of hypotensive emergencies with escalating noradrenaline dose requirements.
Dosage
Adults
Acute Hypotension (concentrate for solution for infusion)
The initial rate of infusion of the diluted solution should be between 10ml/hour and 20ml/hour (0.16ml/minute to 0.33ml/minute). This is equivalent to noradrenaline base 0.4mg/hour to 0.8mg/hour (or noradrenaline acid tartrate 0.8mg/hour to 1.6mg/hour).
Titration of dose
The dose should be titrated in steps of 0.05 to 0.1micrograms/kg/minute (of noradrenaline base). The aim should be to establish a low normal systolic blood pressure (100mmHg to 120mmHg) or to achieve an adequate mean arterial blood pressure (greater than 65mmHg to 80mmHg). Continue treatment as long as vasoactive drug support is indicated.
On going treatment of acute hypotension in adults weighing greater than 50kg (0.08mg/ml and 0.16mg/ml solutions)
The initial dose of noradrenaline base should be between 0.05 and 0.15 micrograms/kg/minute (using less concentrated solutions).
The maintenance dose of noradrenaline base is between 0.05 and 1.5 micrograms/kg/minute.
Children
Acute hypotension (septic shock); Shock secondary to excessive vasodilation (unlicensed)
20 to 100nanograms (base)/kg/minute by continuous intravenous infusion. Titrate according to response.
Maximum dose: 1microgram (base)/kg/minute.
Note: 1mg of noradrenaline base is equivalent to 2mg of noradrenaline acid tartrate. Dose expressed as the base.
Neonates
Acute hypotension (septic shock); Shock secondary to excessive vasodilation (unlicensed)
20 to 100nanograms (base)/kg/minute by continuous intravenous infusion. Titrate according to response.
Maximum dose: 1microgram (base)/kg/minute.
Note: 1mg of noradrenaline base is equivalent to 2mg of noradrenaline acid tartrate. Dose expressed as the base.
Administration
For intravenous infusion via a central venous catheter.
The infusion should be at a controlled rate using either a syringe pump or a drip counter.
Contraindications
Hypertension
Hypovolaemia
Precautions and Warnings
Children under 18 years
Elderly
Restricted sodium intake
Breastfeeding
Diabetes mellitus
Hyperthyroidism
Hypotension - if treating myocardial infarction
Pregnancy
Prinzmetal's angina
Severe hypercapnia
Severe hypoxia
Thromboembolic disorder
Sodium content of formulation may be significant
Not all available brands are licensed for all age groups
Not all available brands are licensed for all body weights
Treatment to be initiated by specialist
Do not mix with other drugs or substances
Do not use if solution is discoloured or particulates are apparent
If extravasation occurs follow local policy & seek expert help immediately
Infusion should be withdrawn gradually to avoid unnecessary hypotension
Monitor blood pressure continuously
Consider the use of fluid and electrolyte replacement
Monitor cardiac function
Life threatening arrhythmias may occur during anaesthesia and surgery
Reduce dose if cardiac arrhythmias occur
Use in conjunction with appropriate blood volume replacement
Monitor blood pressure every 2 minutes at the start of the infusion until the desired blood pressure is obtained, and then every 5 minutes; continue treatment as long as vasoactive drug support is indicated.
Caution is required during syringe or infusion relay to avoid haemodynamic instability.
Pregnancy and Lactation
Pregnancy
Use noradrenaline with caution during pregnancy.
The manufacturer advises caution if noradrenaline is used during pregnancy as it may impair placental perfusion, and can exert a contractile effect on the uterus. This may lead to foetal asphyxia in late pregnancy. Noradrenaline readily crosses the placenta, consistent with its relatively low molecular weight. Studies have shown noradrenaline may induce foetal hypoxia and bradycardia.
Lactation
Use noradrenaline with caution during breastfeeding.
The manufacturer of noradrenaline does not make a recommendation regarding breastfeeding. There is limited information regarding the use of noradrenaline during breastfeeding. It is not known if noradrenaline is excreted in human breast milk, but poor bioavailability and short half life mean it is unlikely to cause an adverse effect in a breastfed infant. High intravenous doses of noradrenaline may reduce milk production or milk letdown.
Side Effects
Anorexia
Anxiety
Bradycardia
Cardiac arrhythmias
Cardiac insufficiency
Cardiomyopathy
Confusion
Dyspnoea
Extravasation necrosis
Glaucoma (closed angle)
Headache
Hypertension
Hypoxia
Increased blood lactate levels
Insomnia
Irritation (injection site)
Nausea
Necrosis (injection site)
Palpitations
Peripheral ischaemia
Peripheral ischaemic gangrene
Plasma volume depletion
Psychosis
Reduced renal blood flow
Respiratory insufficiency
Tachycardia
Tremor
Urinary retention
Vasoconstriction
Vomiting
Weakness
Overdosage
It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.
The following number will direct the caller to the relevant local centre (0844) 892 0111
Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).
Further Information
Last Full Review Date: April 2019
Reference Sources
Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 10th edition (2015) ed. Briggs, G., Freeman, R. Wolters Kluwer Health, Philadelphia.
Summary of Product characteristics: Noradrenaline (Norepinephrine) 0.08mg/ml solution for infusion. Aguettant Ltd. Revised May 2018.
Summary of Product characteristics: Noradrenaline (Norepinephrine) 1mg/ml concentrate for solution for infusion. Aguettant Ltd. Revised October 2018.
Summary of Product characteristics: Noradrenaline (Norepinephrine) 1mg/ml concentrate for solution for infusion. Pfizer UK Ltd. Revised May 2018.
Summary of Product characteristics: Sinora 0.08mg/ml solution for infusion. Sintetica Limited. Revised March 2020.
Summary of Product characteristics: Sinora 0.16mg/ml solution for infusion. Sintetica Limited. Revised March 2020.
NICE Evidence Services Available at: www.nice.org.uk Last accessed: 23 April 2020
US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
Available at: https://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Norepinephrine Last revised: 03 December 2018
Last accessed: 18 April 2019
Medscape UK | Univadis prescription drug monographs & interactions are based on FDB Multilex Content
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