Noradrenaline Injection contains noradrenaline as the acid tartrate. It is a concentrated, potent drug which must be diluted in dextrose containing solutions prior to infusion. An infusion of noradrenaline should be given into a large vein.
Restoration of Blood Pressure in Acute Hypotensive States: Blood volume depletion should always be corrected as fully as possible before any vasopressor is administered. When, as an emergency measure, intra-aortic pressures must be maintained to prevent cerebral or coronary artery ischaemia, noradrenaline can be administered before and concurrently with blood volume replacement.
Diluent: Noradrenaline Injection should be diluted in 5% dextrose in water or 5% dextrose in normal saline solution. This dextrose containing fluids provide protection against significant loss of potency due to oxidation. Administration in saline solution alone is not recommended. Whole blood or plasma, if indicated to increase blood volume, should be administered separately (for example, by use of a Y-tube and individual containers if given simultaneously).
Average Dosage: Add 4mL of Noradrenaline Injection (4mg of Noradrenaline) to 1000mL of a 5% dextrose containing solution. Each mL of this dilution contains 4mcg of the base of noradrenaline (or 8mcg of the acid tartrate). Give this solution by intravenous infusion. Insert a plastic intravenous catheter through a suitable bore needle well advanced centrally into the vein and securely fixed with adhesive tape, avoiding, if possible, a catheter tie-in technique as this promotes stasis. An I.V. drip chamber or other suitable metering device is essential to permit an accurate estimation of the rate of flow in drops per minute.
After observing the response to an initial dose of 2mL to 3mL (from 8mcg to 12mcg of base) per minute, adjust the rate of flow to establish and maintain a low normal blood pressure (usually 80 mmHg to 100 mmHg systolic) sufficient to maintain the circulation to vital organs. In previously hypertensive patients, it is recommended that the blood pressure should be raised no higher than 40mmHg below the pre-existing systolic pressure. The average maintenance dose ranges from 0.5mL to 1mL per minute (from 2mcg to 4mcg of base).
High Dosage: Great individual variation occurs in the dose required to attain and maintain an adequate blood pressure. In all cases, dosage of noradrenaline should be titrated according to the response of the patient. Occasionally much larger or even enormous daily doses (as high as 68mg base or 17 ampoules) may be necessary if the patient remains hypotensive, but occult blood volume depletion should always be suspected and corrected when present. Central venous pressure monitoring is usually helpful in detecting and treating this situation.
Fluid Intake: The degree of dilution depends on clinical fluid volume requirements. If large volumes of fluid (dextrose) are needed at a flow rate that would involve an excessive dose of the pressor agent per unit of time, a solution more dilute than 4mcg per mL should be used. On the other hand, when large volumes of fluid are clinically undesirable, a concentration greater than 4mcg per mL may be necessary.
Duration of Therapy: The infusion should be continued until adequate blood pressure and tissue perfusion are maintained without therapy. Infusions of noradrenaline should be reduced gradually, avoiding abrupt withdrawal. In some of the reported cases of vascular collapse due to acute myocardial infarction, treatment was required for up to six days.
Adjunctive Treatment in Cardiac Arrest: Infusions of noradrenaline are usually administered intravenously during cardiac resuscitation to restore and maintain an adequate blood pressure after an effective heartbeat and ventilation have been established by other means. [Noradrenaline's powerful beta-adrenergic stimulating action is also thought to increase the strength and effectiveness of systolic contractions once they occur.]
Average Dosage: To maintain systemic blood pressure during the management of cardiac arrest, noradrenaline is used in the same manner as described under Restoration of Blood Pressure in Acute Hypotensive States.
Parenteral drug products should be inspected visually for particulate matter and discolouration prior to use, whenever solution and container permit.
Do not use the solution if its colour is pinkish or darker than slightly yellow or if it contains a precipitate.
Avoid contact with alkalis and oxidising agents.
ROUTE OF ADMINISTRATION: For IV Infusion only.