For the restoration of blood pressure in certain acute hypotensive states (e.g. pheochromocytomectomy, sympathectomy, poliomyelitis, spinal anesthesia, myocardial infarction, septicemia, blood transfusion, and drug reactions). As an adjunct in the treatment of cardiac arrest and severe hypotension. To restore and maintain an adequate blood pressure after an effective heartbeat and ventilation have been established by other means.
Norepinephrine 4 mg
Up to 18 Years
Safety and effectiveness in pediatric patients has not been established.
65 Years Old and Above
Dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other therapy.
Norepinephrine infusions should not be administered into the veins in the leg in elderly patients.
Raivas injection is a concentrated, potent injection which must be diluted in dextrose containing solutions prior to infusion. An infusion of norepinephrine 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 ischemia, norepinephrine can be administered before and concurrently with blood volume replacement.
Norepinephrine should be diluted in five percent (5%) dextrose solution or five percent (5%) dextrose with sodium chloride solution. These dextrose containing fluids provide protection against significant loss of potency due to oxidation. .
Add 4 ml (4 mg) from norepinephrine’s ampoules to 1,000 ml of a 5% dextrose containing solution. Each ml of this dilution contains 4 micrograms of the base of norepinephrine. Give this solution by intravenous infusion. After observing the response to an initial dose of 2 ml to 3 ml (from 8-12 mcg 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 40 mmHg below the pre-existing systolic pressure. The average maintenance dose ranges is from 0.5-1 ml per minute (from 2 mcg to 4 mcg of base).
Dosage of norepinephrine should be titrated according to the response of the patient. Occasionally much larger or even enormous daily doses (as high as 68 mg 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.
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 4 mcg per ml should be used. On the other hand, when large volumes of fluid are clinically undesirable, a concentration greater than 4 mcg 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 norepinephrine should be reduced gradually, avoiding abrupt withdrawal.
Adjunctive Treatment in Cardiac Arrest
To maintain systemic blood pressure during the management of cardiac arrest, norepinephrine is used in the same manner as described under “restoration of blood pressure in acute hypotensive states”.