Noradrenaline

Noradrenaline – the drug used for bystry recovery of arterial pressure.

Form of release and structure

Noradrenaline is issued in the form of a concentrate for preparation of solution for intravenous administration: transparent, colourless or brownish-yellow (in colourless glass ampoules on 2, 4 or 8 ml, on 5 ampoules in blister strip packagings, on 1 or 2 packagings in a cardboard pack).

Is a part of 1 ml of a concentrate:

• Active ingredient: Norepinephrinum hydrotartrate (in the form of monohydrate) – 2 mg (it is equivalent to 1 mg of Norepinephrinum of the basis);
• Auxiliary components: Acidum hydrochloricum or sodium hydroxide – to pH 3,0-4,5, sodium chloride – 8,4 mg, water for injections – to 1 ml.

Indications to use

Noradrenaline is appointed for bystry recovery of arterial pressure at its acute decrease.

Contraindications

Absolute:

• The arterial hypotension connected with a hypovolemia (except cases when drug is used for maintenance of a coronary and brain blood-groove before the end of the treatment directed to completion of volume of the circulating blood);
• The expressed hypercapnia and hypoxia;
• Carrying out cyclopropane and galotanovy general anesthesia (because of risk of development of arrhythmias of heart);
• Hypersensitivity to drug components.

Relative (Noradrenaline should be applied with care in the presence of the following diseases / states):

• Acute heart failure, the expressed left ventricular failure;
• Printsmetal's stenocardia;
• Recently postponed myocardial infarction;
• Thrombosis of coronary, peripheral or mesenteric vessels (because of risk of increase in a zone of a heart attack and aggravation of ischemia);
• Insufficient blood circulation.

The feeding and pregnant women can enter Noradrenaline only in cases if the advantage of use of drug for health of mother is higher than possible harm for the child.

Route of administration and dosage

Noradrenaline should be entered only intravenously, by means of devices of the central venous access (for reduction of risk of an ekstravazation and a further necrosis of fabrics).

The doctor establishes a solution dose individually, based on a clinical condition of the patient.

Depending on a way of introduction of Noradrenaline, the concentrate is parted as follows:

• Spray infusional pomp: it is necessary to add 46 ml of 5% of solution of a dextrose to 4 ml of drug of 1 mg/ml;
• Dropper: it is necessary to add 460 ml of solution of a dextrose of 5% to 40 ml of drug of 1 mg/ml.

In both ways of cultivation final concentration of the received solution for intravenous administration has to make 80 mg/l (40 mg/l of Norepinephrinum of the basis are equivalent). It is impossible to mix Noradrenaline with other medicines.

The recommended initial dose of drug and speed of maintaining – 0,1-0,3 mkg/kg a minute. Infusion speed is progressively increased step by step titration, on 0,05-0,1 mkg/kg a minute, according to observed pressor effect till the moment, the desirable normotoniya will not be reached yet. For achievement and maintenance of a normotoniya of a dose for different patients can differ. The purpose of performing therapy is achievement of the lower bound of norm of systolic pressure (from 100 to 120 mm hg) or achievement of sufficient level of average value (higher than 65-80 mm hg depending on a condition of the patient).

Before the beginning or during treatment correction of a hypoxia, a hypovolemia, hypercapnia and acidosis is necessary.

Drug needs to be used together with appropriate completion of volume of the circulating blood.

To avoid developing of hypertensia, duration, rate of administering and a dose of solution of Noradrenaline are defined taking into account data of control of cordial activity and under obligatory medical control of arterial pressure (before achievement of a normotoniya – each 2 minutes, then each 5 minutes throughout all infusion).

Therapy needs to be reduced step by step as sharp drug withdrawal can lead to developing of acute hypotension.

Duration of a course can vary from several hours to 6 days.

Because of danger of development of necroses it is necessary to be careful of introduction of Noradrenaline intramusculary and subcutaneously.

Side effects

• Central nervous system: sleeplessness, alarm, headache, psychotic states, cephalalgia, tremor, weakness, decrease in attention, confusion of consciousness, vomiting, nausea, anorexia;
• Cardiovascular system: the hypoxia of fabrics and arterial hypertension, ischemic disturbances (connected with powerful vasoconstriction which can lead to a cold snap and pallor of the person and extremities), tachycardias, bradycardia, a heart consciousness, arrhythmias, increase in sokratitelny ability of a cardiac muscle because of beta and adrenergic effect on heart (chronotropic and inotropic), an acute heart failure;
• Urinary system: urination delay;
• Respiratory system: pains in the field of a mediastinum and a breast, an asthma, respiratory insufficiency, breath difficulty;
• Immune system: difficulty of breath and allergic reactions (with hypersensitivity to drug components);
• Organ of sight: acute glaucoma (at patients with anatomic predisposition – with closing of a corner of an anterior chamber of an eyeglobe);
• Local reactions: irritation in an injection site or development of a necrosis.

At bystry introduction of Noradrenaline can be observed: fever, headache, tachycardia, cooling of extremities.

Long administration of drug for maintenance of arterial pressure in the absence of recovery of volume of the circulating blood can lead to development of the following side effects: a heavy visceral and peripheral vasomotor spasm, a hypoxia of fabrics, decrease in a renal blood-groove, reduction of production of urine, increase in level of a lactate in blood serum.

With hypersensitivity to drug components during therapy in usual or high doses the dispepsichesky phenomena and the expressed increase in arterial pressure which is followed by a photophobia, a headache, pallor of integuments, the pricking retrosternal pain, vomiting and increase in sweating can be observed.

Special instructions

Simultaneous use of Noradrenaline with monoamine oxidase inhibitors of triptilinovy and imipraminovy type is not recommended (because of risk of development of the long and expressed increase in arterial pressure).

Elderly patients can be especially sensitive to drug influence therefore in order to avoid hypertensia during injection it is necessary often (each 2 minutes) to check a flow rate and blood pressure.

At long use of Noradrenaline decrease in plasma volume can be observed (it is necessary to carry out correction in order to avoid returnable hypotonia at drug withdrawal).

At development of disturbances of a cordial rhythm during injection it is necessary to reduce a dose.

At use of Noradrenaline for patients it is necessary to be careful with a diabetes mellitus and a hyperthyroidism.

For decrease in risk of development of an ekstravazation and the subsequent necrosis of fabrics at administration of drug it is necessary to control constantly provisions of a needle in a vein. The place of infusion needs to be checked for infiltration emergence (a free flow) often. To avoid course of drug from a vessel (ekstravazation) it is necessary to work with care. Because of vein vasoconstriction with a hyperpermeability course of Noradrenaline in fabrics which surround the vein used for infusion is possible. To weaken effect of local vasoconstriction it is necessary to replace the place of infusion.

At course of Noradrenaline from an injection or a vessel by a vein there can be blanching and further destruction of fabrics (because of vasoconstrictive effect of the medicine on vessels). At hit of Noradrenaline by a venous blood-groove to the place of an injection enter 5-10 ml of a mezilat of phentolamine into 10-15 ml of normal saline solution.

After cultivation of a concentrate of Noradrenaline, the received solution needs to be used for 12 hours.

Medicinal interaction

At simultaneous use of Noradrenaline with some medicines there can be following effects:

• Cardiac glycosides, quinidine, tricyclic antidepressants: increase in risk of development of arrhythmias;
• Means for inhalation general anesthesia (изофлуран, a halothane, chloroform, энфлуран, метоксифлуран, cyclopropane): increase in risk of development of ventricular arrhythmias;
• Alpha adrenoblockers (лабеталол, доксазозин, phentolamine, phenoxybenzamine, теразозин, Prazozinum, талазозин) and other drugs with alpha and adrenoceptor blocking activity (локсапин, a haloperidol, thioxanthenes, fenotiazina): counteraction of vasoconstrictive action;
• Hypotensive drugs, diuretics: decrease in effect of action of Norepinephrinum;
• Maprotilinum, tricyclic antidepressants: strengthening of pressor action, cardiovascular effects, arrhythmias, tachycardias;
• Doksapram, cocaine: mutual strengthening of hypertensive action;
• Beta adrenoblockers: mutual weakening of action;
• Nitrates: weakening of anti-anginal action;
• Furasolidone, monoamine oxidase inhibitors, селегилин, Procarbazinum: strengthening and lengthening of pressor effect;
• Hormones of a thyroid gland: increase in risk of emergence of coronary insufficiency against the background of stenocardia;
• Oxytocin or alkaloids of an ergot: strengthening of angiotonic and vasoconstrictive effect.

Terms and storage conditions

To store in protected from light, the place, unavailable to children, at a temperature up to 25 °C.

Period of validity – 2 years.