Upload
dhexel
View
264
Download
0
Embed Size (px)
Citation preview
Norepinephrine
Nick Rathert, MD
For the REMO Medical Advisory Committee
Norepinephrine (Levophed®)
• Classification: Adrenergic agent
• Onset: Rapid (1-2 minutes max)
• Duration of action: Short (1-2 minutes)
Background
• Previously viewed as one of many options for hypotension
– Pressor of choice for essentially all hypotension
– Surviving Sepsis treatment of choice
Adrenergic Mechanism
• Beta 1 – stimulates cardiac rate and contractility
• Alpha 1 – stimulates peripheral vasoconstriction
• Beta 2 – no effect on airway smooth muscle
Goals of Care
• Reversal of shock state
– A state of tissue hypoperfusion
• Increase perfusion to end organs via increased systemic vascular resistance
• Good initial BLS is paramount – recognition
• Good ALS is key – fluid resuscitation
• Don’t squeeze the pipes until the tank is full!
Indications?
Nearly Any Shock State!!ROSC
Neurogenic
Cardiogenic/LVAD
Anaphylactic
Septic
BUT – Correct Volume First
Contraindications
• There are no clear contraindications for norepinephrine in EMS
• Relative contraindication would be depleted intravascular volume
– Patient must receive appropriate fluid resuscitation first
Cautions
• Remember to “fill the tank” before you add a pressor
• Must ensure and reevaluate access
– Infiltration can lead to severe tissue necrosis
– If infiltration is suspected, stop drip immediately and notify hospital staff upon arrival
Specific information
• No pre-mix available
• Hospital concentrations will vary
• Supplied: 1mg/ml in 4 ml vial
• Dosing: Continuous Infusion
• Pregnancy category C
Administration
• Supplied as 4 mg in 4 ml
• Mix into NS 1,000 ml
• 4 mg in 1000ml = 4 mcg/ml
• Dosing? Start at 2 mcg/min or 0.5 to 5 ml/minute
– Titrate to a maximum of 20 mcg/min MAP >65
Protocol
Protocols
Thanks.