Please note that this guidance is currently undergoing review by Safer Care Victoria to ensure the content is up to date. In the meantime, we recommend that you also refer to more contemporaneous evidence where possible.
This best practice guideline has been designed for critical care units, however, it can be applied to other areas within your health service who use vasoactive infusions, such as anaesthetics, cardiology and emergency departments.
Mechanism of action/pharmacology
Noradrenaline is a vasoconstrictor that predominantly stimulates α1 receptors to cause peripheral vasoconstriction and increase blood pressure.
It also has some β1 receptor agonist activity that results in a positive inotropic effect on the heart at higher doses.1,2
Onset of action: 1–2 minutes.2
Duration of action: 5–10 minutes.2
Half-life: 3 minutes.2
Indications
To increase blood pressure in acute, severe, hypotensive states when low systemic vascular resistance persists despite adequate fluid resuscitation.2
Noradrenaline is the vasopressor of choice for managing septic shock.3
Precautions
- Hypersensitivity to noradrenaline or sulfites (some brands contain sodium metabisulfite)4
- Hypotension due to uncorrected hypovolaemia.4
Medication presentation
4 mg/4 mL (1:1000) of noradrenaline base per vial.
Medication storage
Store vials below 25°C. Do not freeze. Protect from light.5
Infusion solutions are stable for up to 24 hours.6
Preparation
|
|
Infusion pump |
Syringe driver |
|||
|---|---|---|---|---|---|
|
Prescribe |
4 mg in 66 mL |
6 mg in 100 mL |
16 mg in 266 mL |
32 mg in 532 mL |
3 mg in 50 mL |
|
Make up infusion in |
100 mL bag of glucose 5%* |
100 mL bag of glucose 5%* |
250 mL bag of glucose 5%* |
500 mL bag of glucose 5%* |
Glucose 5% (to a total of 50 mL in the syringe) |
|
Volume to be removed from IV bag |
38 mL |
6 mL |
Nil |
Nil |
Not applicable |
|
Drug dose to be added |
4 mg (4 mL) |
6 mg (6 mL) |
16 mg (16 mL) |
32 mg (32 mL) |
3 mg (3 mL) |
|
Final volume |
66 mL |
100 mL |
266 mL |
532 mL |
50 mL |
|
Final concentration |
60 microg/mL |
60 microg/mL |
60 microg/mL |
60 microg/mL |
60 microg/mL |
|
1 mL/hr = |
1 microg/min |
1 microg/min |
1 microg/min |
1 microg/min |
1 microg/min |
*Glucose 5% can protect against excessive oxidation and consequent loss of potency.6
However, noradrenaline is also compatible with glucose in sodium chloride solutions, Hartmann’s and sodium chloride 0.9%2
Administration - this guideline is intended for central access only
Administer continuous intravenous infusion through a central access line.
Infusions should be administered via a syringe driver or infusion pump, preferably with medication error reduction software enabled.
Avoid administration in lines where other drugs or fluids may be bolused or flushed.
Dosing
Starting dose: 2 to 10microg/min
Titrate in accordance with prescribed blood pressure parameters – for example, by increments of 0.5 to 2microg/min
Usual dose range: 0.5 to 30microg/min
Maximum dose: up to 100microg/min in extreme cases7
Noradrenaline should not be ceased abruptly.
Monitoring
- Continuous blood pressure and cardiac monitoring for the duration of the infusion5
- Monitor fluid balance
- Assess for organ ischaemia (including myocardium, kidneys, gastrointestinal tract and peripheral extremities) – see ‘Side effects’ for more information.
Side effects
- Bradycardia – as a reflex to the increase in blood pressure4
- Arrhythmias4
- Myocardial, mesenteric, renal or peripheral (digital) ischaemia – can manifest as acute myocardial infarction, gastrointestinal infarction, decreased urine output/creatinine clearance or gangrene.2
Compatibilities
Consult the following references, which are available online through the Clinicians Health Channel:
- Australian injectable drugs handbook
- Trissel’s™ in IV compatibility (Micromedex) – from the site’s homepage, select the ‘IV Compatibility’ tab.
Important drug interactions
- Monoamine oxidase inhibitors (MAOIs) (including reversible, non-selective agents such as linezolid) inhibit the metabolism of noradrenaline. Dose noradrenaline conservatively.4,6,8
- Tricyclic antidepressants (TCAs) potentiate the effects of noradrenaline by inhibiting its uptake into adrenergic nerve endings, resulting in high levels of circulating noradrenaline. Dose noradrenaline conservatively.4,6,8
- Entacapone is a catechol-O-methyltransferase (COMT) inhibitor, which may inhibit the metabolism of noradrenaline, increasing the risk of side effects. Dose noradrenaline conservatively.9
References
- Manaker S. Use of vasopressors and inotropes. UpToDate 2018 [online] (accessed 9 January 2018). Available from: https://www.uptodate.com/contents/use-of-vasopressors-and-inotropes?search=use%20of%20vasopressors%20and%20inotropes&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
- Wiggins B, Sanoski C. Emergency cardiovascular pharmacotherapy: a point-of-care guide. American Society of Health-System Pharmacists, Bethesda, MD, 2012
- Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2016. Intensive Care Medicine 2017; 43(3):304–377
- MIMS [online] (accessed 9 January 2018)
- Australian injectable drugs handbook (AIDH) [online] (accessed 9 January 2018)
- Micromedex [online] (accessed 9 January 2018)
- University College London Hospitals (UCL). UCL hospitals injectable medicines administration guide: pharmacy department, 3rd edn. Wiley-Blackwell, 2013
- Australian medicines handbook (AMH) [online] (accessed 9 January 2018)
- Lexicomp [online] (accessed 9 January 2018)
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Overarching guidance
Acknowledgements
We would like to thank the pharmacists involved in writing the guidelines: Melissa Ankravs, Melanie Kowalski, Rachel Fyfe, Robyn Ingram, Annalie Jones, Susan Trevillian, and Lucy Sharrock.
Version history
Last reviewed: December 2018
Due for review: December 2021