Liverpool Hospital ICU Guideline: Pharmacology Intensive Care Unit

noradrenaline

Drug Guideline Title: Noradrenaline (Levophed)

Summary:
Noradrenaline is a naturally occurring catecholamine with inotropic and vasoconstrictor
effects

Approved by: ICU Director, ICU - NUM

Publication (Issue) Date: July 2014

Next Review Date: July 2017

Replaces Existing Drug Guideline: noradrenaline

Previous Review Dates: 2005, 2011

1. Introduction contains:
The risk addressed by this policy:

Patient safety.

The Aims / Expected Outcome of this policy:

Noradrenaline will be administered safely and without adverse side effects by accredited
staffs who comply with hospital and ICU guidelines and policies.

Related Standards or Legislation

NSQHS Standard 1 Governance

National Standard 4 Medication Safety

Related Policies
 LH_PD2013_C03.01 Drug Administration
 LH_PD2010_C03.00 Drug Prescribing
 LH_PD2008_C03.12 Administration of IV Medication

2. Policy Statement:
• All care provided within Liverpool Hospital will be in accordance with infection control,
manual handling and minimisation and management of aggression guidelines.
• Medications are to be prescribed and signed by a medical officer/authorised nurse
practitioner (NP) unless required during an emergency.
• All drugs administered during an emergency (under the direction of a medical
officer/authorised nurse practitioner) are to be documented during the event, then
prescribed and signed following the event.
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• Medications are to be given at the time prescribed (as close to the time as is possible
when multiple drugs require ‘same time’ administration and, when the nurse is caring
for more than one patient, recognition is given to a possible short delay to
administration – antibiotics and other lifesaving drugs are to be prioritised) and are to
be signed by the administering nurse.
• Parenteral medication prescriptions and the drug are to be checked with a second
registered or endorsed enrolled nurse prior to administration. The “rights of drug
administration” must be followed: right: patient, drug, dose, route, administration, time,
reason for the drug, documentation, education and evaluation/outcome.
• Adverse drug reactions are to be documented and reported to a medical officer.
• Medication errors are to be reported using the hospital electronic reporting system:
IIMS.
• Guidelines are for adult patients unless otherwise stated.

• Noradrenaline infusions may be titrated or weaned by accredited RNs.

• Medical Officers must ensure that titration and/or weaning parameters are specified and
documented on the management plan, and have been discussed with the nurse
assigned to that patient.
• The maximum concentration of noradrenaline infusion is: 16mg noradrenaline in 50mL
sterile 5% glucose.
• For a concentration of noradrenaline 16mg in 5% glucose 50mL - do not exceed an
hourly rate of 19mL. If the patient requires  20mL/hr, contact the senior registrar (SR)
or/and the ICU Consultant on call for further review and management.
• A patient requiring inotropic support of  20mL/hr of noradrenaline 16mg/50mL 5%
glucose must be reviewed to ensure an appropriate nursing ratio is allocated.
• Noradrenaline must always be administered via a dedicated lumen of a central line, and
never “piggybacked” with other drugs or fluids. Where multiple infusions are required, it
may be acceptable to administer Noradrenaline together with another compatible
inotrope / vasopressor via a three-way tap.
• Infusion should only be administered via a central line as it can cause necrosis from
extravasation.
• Blood pressure should be continuously monitored
• Noradrenaline infusions must be administered by syringe pump or infusion pump.
• When commencing a syringe infusion of noradrenaline, an additional syringe and
driver is assembled and attached to the 3-way tap. This is available to facilitate
syringe change when the infusion ends with minimal interruption to dose and rate
of delivery. It also ensures that a spare infusion is always available.

For the purposes of this Policy, an accredited RN is: a Registered Nurse (RN) who has
completed the required self directed learning package, has completed the competency
assessment and has been accredited by a Clinical Nurse Educator/Clinical Nurse
Consultant, to administer/titrate inotropic / vasopressor drugs when caring for an Intensive
Care Unit (ICU) Patient. The Clinical Nurse Educator/Clinical Nurse Consultant may deem
the nurse competent if the nurse has previous documented experience/qualifications.

3. Principles / Guidelines
Actions
Noradrenaline is a naturally occurring catecholamine.
It stimulates the alpha () and beta ()-1 receptors in the sympathetic nervous system.
• -stimulation causes peripheral, renal, splanchnic and pulmonary vasoconstriction.
• -1 stimulation increases myocardial contractility, with less tachycardia produced than
with adrenaline.
The -1 adrenergic effect are prominent in the lower dose range, while -adrenergic
effects predominate at higher doses.

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Indications
• Septic shock.
• Anaphylaxis with labile BP unresponsive to adrenaline.
• Hypotension unresponsive to fluid resuscitation.
• Cardiogenic shock unresponsive to other inotropes.
• Maintenance of adequate blood pressure in the presence hypotension associated with
brain stem death.
• Hypertensive agent of choice in the management of subarachnoid haemorrhage.

Contraindications
• Hypovolaemia. Instituting a noradrenaline infusion for treatment of hypotension should
always be in the presence of adequate fluid resuscitation.
• Patients taking monoamineoxidase inhibitors (MAOIs), or within 14 days of such
treatment.
• Mesenteric or peripheral vascular thrombosis (unless life saving)
• Cyclopropane, halothane anaesthesia

Precautions
 Severe peripheral vascular disease.
 Prolonged use
 Sulfite sensitivity
 Abrupt withdrawal, as this will be associated with sudden fall in blood pressure.
Noradrenaline should be gradually weaned to the desired MAP /SBP.

Significant Interactions
 Tricyclic antidepressants
 MAOIs
 Incompatibilities e.g barbituates, oxidising agents, chorpheniramine, chlorothiazide,
nitrofurantoin, phenytoin, sodium bicarbonate, sodium iodide, streptomycin,
sulfadiazine, sulfafurazole, thiopentone, pantoprazole.

Adverse Effects
• Tachycardia.
• Dysrhythmias.
• Hypertension.
• Exacerbation of myocardial ischaemia.
• Tissue necrosis if extravasation occurs.
• Reduced blood flow to ‘non-vital’ tissues, especially the skin and gut.
• Renal vasoconstriction may decrease renal blood flow.
• Hyperglycaemia.

Presentation
Noradrenaline 1:1000, 4mg base in 4mL vial

Administration Guidelines
Infusion:
• Single strength infusion: Dilute 4mg noradrenaline base with sterile 5% glucose to total
50mL, to give a final concentration of 80micrograms/mL.
• Commence at 5mL/hr and titrate the infusion using haemodynamic parameters, which
have been discussed with the medical officer and documented on the management plan.
This maybe a desired MAP or SBP.
• If necessary, increase the infusion by 0.5 to 1mL/hr every 2 minutes, while
monitoring the patient for the desired response.
• If there is significant increase in noradrenaline requirement notify the ICU registrar.
• Do not exceed a 'quad strength' infusion of 16mg noradrenaline in 50mL 5% glucose.
• Do not exceed an infusion rate of > 19mL/hr of 16mg noradrenaline in 50mL 5% glucose.

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If the patient requires  20mL/hr of quad strength noradrenaline, contact the ICU Senior
Registrar and / or the ICU consultant. Nurse: Patient ratio becomes 1:1.

Table: Concentration for Single, Double and Quad strength infusions.

Noradrenaline Dilutent Final Concentration

Single Strength 4mg 50ml of 0.9% sodium 80mcg /ml
chloride
Double Strength 8mg 50ml of 0.9% sodium 160mcg /ml
chloride
Quad Strength 16mg 50ml of 0.9% sodium 320mcg /ml
chloride

If sudden and severe hypotension occurs:

• Check that the syringe is not empty, lines are not kinked and the pump is not turned off
or access lost.
• If the problem is related to the patient, increase the infusion rate initially by 5 - 10mL
while monitoring the patient for the desired effects. Consider need for assistance.
• If patient fails to respond, contact the medical officer urgently.
• Instituting a noradrenaline infusion for treatment of hypotension should always be in the
presence of adequate fluid resuscitation.

Note:
• Weaning a noradrenaline infusion should commence as soon as the patient is stable.
Aim to administer the lowest dose that achieves the desired effect.
• Decrease the infusion rate by 0.2 to 0.5mL/hr, no more frequently than every 10-15
minutes while observing the patient for signs of deterioration.
• Ensure an adequate circulating fluid volume is maintained.

Clinical Considerations
• Noradrenaline ampoules are to remain stocked both in the pharmacy area and in the
ICU patient bed area.
• As a general rule, inotropes and vasopressors should never be purged. Purging results
in uneven doses of the drug and gross changes to serum concentration resulting in
unstable haemodynamic parameters.
• Inotropes and vasopressors need to be regulated by continuous infusion to maintain a
consistent dose delivery and haemodynamic control. Continuous monitoring of blood
pressure with arterial lines is necessary to help close monitoring and titration of
therapy.
• Preparing the next (syringe or flask) should never be left until the last minute. Inotrope
and vasopressor infusions should never run out. Some patients are very dependent on
these and will not tolerate them being turned off for even a short period of time (they
have a short half-life). It is essential to have the next infusion prepared as soon as the
current syringe/ flask are connected and a clear process for changing between
completed and new infusions so that serum concentration is maintained.
• Significant levels of vasoconstriction may lead to peripheral necrosis and extremities
should be monitored
• These drugs must be delivered by an infusion device so that the dose is delivered in a
controlled manner and the rate of delivery can be exactly titrated.

Syringe Change – When changing from a near completed infusion to a new syringe:
 Commence new infusion, prior to the completion of the old infusion.
 Observe MAP, when this begins to rise, you may safely cease the old infusion.

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 Closely monitor BP.
 If BP falls, increase infusion rate.

4. Performance Measures
All incidents are documented using the hospital electronic reporting system: IIMS and
managed appropriately by the NUM and staff as directed.

5. References / Links

1. The Society of Hospital Pharmacists of Australia 2011, The Australian Injectable Drugs
th
Handbook, 5 Edition, SHPA publications, Australia.
2. MIMS Online, CIAP: NSW Health Department, Copyright MIMS Australia Pty Ltd 2013.
http://www.mims.hcn.net.au/. http://www.mims.hcn.net.au/
th
3. eTherapeutic Guidelines: CIAP 2013, http://www.tg.org.au/, viewed 11 Dec 2013
th
4. Thomas Reuters, Micromedex 2.0, http://www.micromedex.com/, viewed 11 December 2013.

Author: CNC – ICU (S. Shunker);

Reviewers: ICU – CNC, CNE, NM, NUM, Staff Specialists, CNS ‘s, Medical Director,
Pharmacist
Endorsed by: A/ Proff M. Parr, Director ICU.

See Infusion Rate – Table on the next page.

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noradrenaline 80micrograms/mL Infusion (single strength)

(Answers are in micrograms/kg/min, corrected to 2 decimal places)
Weight (kg)
mL/hr 50 60 70 80 90 100 110 120
0.5 0.01 0.01 0.01 0.01 0.01 0.01 0.00 0.00
1.0 0.03 0.02 0.02 0.02 0.01 0.01 0.01 0.01
1.5 0.04 0.03 0.03 0.03 0.02 0.02 0.02 0.02
2.0 0.05 0.04 0.04 0.04 0.03 0.03 0.02 0.02
2.5 0.07 0.05 0.05 0.05 0.04 0.03 0.03 0.03
3.0 0.08 0.07 0.06 0.06 0.04 0.04 0.04 0.03
3.5 0.09 0.08 0.07 0.07 0.05 0.05 0.04 0.04
4.0 0.11 0.09 0.08 0.08 0.06 0.05 0.05 0.04
4.5 0.12 0.10 0.09 0.08 0.07 0.06 0.05 0.05
5.0 0.13 0.11 0.10 0.09 0.07 0.07 0.06 0.06
5.5 0.15 0.12 0.10 0.10 0.08 0.07 0.07 0.06
6.0 0.16 0.13 0.11 0.11 0.09 0.08 0.07 0.06
6.5 0.17 0.14 0.12 0.12 0.10 0.09 0.08 0.07
7.0 0.19 0.15 0.13 0.13 0.10 0.09 0.08 0.08
7.5 0.20 0.17 0.14 0.13 0.11 0.10 0.09 0.08
8.0 0.21 0.18 0.15 0.14 0.12 0.11 0.10 0.09
8.5 0.23 0.19 0.16 0.15 0.13 0.11 0.10 0.09
9.0 0.24 0.20 0.17 0.16 0.13 0.12 0.11 0.10
9.5 0.25 0.21 0.18 0.17 0.14 0.13 0.12 0.11
10.0 0.27 0.22 0.19 0.18 0.15 0.13 0.12 0.11
10.5 0.28 0.23 0.20 0.18 0.16 0.14 0.13 0.12
11.0 0.29 0.24 0.21 0.19 0.16 0.15 0.13 0.12
11.5 0.31 0.26 0.22 0.20 0.17 0.15 0.14 0.13
12.0 0.32 0.27 0.23 0.21 0.18 0.16 0.15 0.13
12.5 0.33 0.28 0.24 0.22 0.19 0.17 0.15 0.14
13.0 0.35 0.29 0.25 0.23 0.19 0.17 0.16 0.14
13.5 0.36 0.30 0.26 0.23 0.20 0.18 0.16 0.15
14.0 0.37 0.31 0.27 0.24 0.21 0.19 0.17 0.16
15.0 0.40 0.33 0.29 0.25 0.22 0.20 0.18 0.17
16.0 0.43 0.35 0.30 0.27 0.24 0.21 0.19 0.18
17.0 0.45 0.37 0.32 0.28 0.25 0.23 0.21 0.19
18.0 0.48 0.40 0.34 0.30 0.27 0.24 0.22 0.20
19.0 0.51 0.42 0.36 0.32 0.28 0.25 0.23 0.21
20.0 0.53 0.44 0.38 0.33 0.30 0.27 0.24 0.22
21.0 0.56 0.46 0.40 0.35 0.31 0.28 0.25 0.23
22.0 0.59 0.48 0.42 0.37 0.33 0.30 0.27 0.24
23.0 0.61 0.51 0.44 0.38 0.34 0.31 0.28 0.26
24.0 0.64 0.53 0.46 0.40 0.36 0.32 0.30 0.27
25.0 0.67 0.55 0.48 0.42 0.37 0.33 0.30 0.28

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Noradrenaline 160micrograms/mL Infusion (double strength)
(Answers are in micrograms/kg/min, corrected to 2 decimal places)

Weight (kg)

mL/hr 50 60 70 80 90 100 110 120

0.5 0.03 0.02 0.02 0.02 0.01 0.01 0.01 0.01
1.0 0.05 0.04 0.04 0.03 0.03 0.03 0.02 0.02
1.5 0.08 0.07 0.06 0.05 0.04 0.04 0.04 0.03
2.0 0.11 0.09 0.08 0.07 0.06 0.05 0.05 0.04
2.5 0.13 0.11 0.10 0.08 0.07 0.06 0.06 0.06
3.0 0.16 0.13 0.11 0.10 0.09 0.08 0.07 0.07
3.5 0.19 0.16 0.13 0.12 0.10 0.09 0.08 0.08
4.0 0.21 0.18 0.15 0.13 0.12 0.11 0.10 0.09
4.5 0.24 0.20 0.17 0.15 0.13 0.12 0.11 0.10
5.0 0.27 0.22 0.19 0.17 0.15 0.13 0.12 0.11
5.5 0.29 0.24 0.21 0.18 0.16 0.15 0.13 0.12
6.0 0.32 0.27 0.23 0.20 0.18 0.16 0.15 0.13
6.5 0.35 0.29 0.25 0.22 0.19 0.17 0.16 0.14
7.0 0.37 0.31 0.27 0.23 0.20 0.19 0.17 0.16
7.5 0.40 0.33 0.29 0.25 0.22 0.20 0.18 0.16
8.0 0.43 0.36 0.30 0.27 0.23 0.21 0.19 0.18
8.5 0.45 0.38 0.32 0.28 0.25 0.23 0.21 0.19
9.0 0.48 0.40 0.34 0.30 0.27 0.24 0.22 0.20
9.5 0.51 0.42 0.36 0.32 0.28 0.25 0.23 0.21
10.0 0.53 0.44 0.38 0.33 0.30 0.27 0.25 0.22
10.5 0.56 0.47 0.40 0.35 0.31 0.28 0.25 0.23
11.0 0.59 0.49 0.42 0.37 0.33 0.29 0.27 0.24
11.5 0.61 0.51 0.44 0.38 0.34 0.31 0.28 0.26
12.0 0.64 0.53 0.46 0.40 0.36 0.32 0.29 0.27
12.5 0.67 0.56 0.48 0.42 0.37 0.33 0.30 0.28
13.0 0.69 0.58 0.50 0.43 0.39 0.35 0.32 0.29
13.5 0.72 0.60 0.51 0.45 0.41 0.36 0.33 0.30
14.0 0.75 0.62 0.53 0.48 0.43 0.37 0.34 0.31
15.0 0.80 0.67 0.55 0.50 0.44 0.40 0.36 0.33
16.0 0.85 0.71 0.57 0.53 0.47 0.43 0.39 0.36
17.0 0.91 0.76 0.65 0.57 0.50 0.45 0.41 0.38
18.0 0.96 0.80 0.69 0.60 0.53 0.48 0.44 0.40
19.0 1.01 0.84 0.72 0.63 0.56 0.51 0.46 0.42
20.0 1.06 0.89 0.76 0.67 0.59 0.53 0.48 0.44
21.0 1.12 0.93 0.80 0.70 0.62 0.56 0.51 0.47
22.0 1.17 0.98 0.84 0.73 0.65 0.59 0.53 0.49
23.0 1.23 1.02 0.88 0.77 0.68 0.61 0.56 0.51
24.0 1.28 1.07 0.91 0.80 0.71 0.64 0.58 0.53
25.0 1.33 1.11 0.95 0.83 0.74 0.67 0.61 0.56

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