Noradrenaline Effect of adrenaline or noradrenaline with/without lidocaine … - IdmcrackfreedownloadInfo

Noradrenaline Effect of adrenaline or noradrenaline with/without lidocaine …

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Noradrenaline

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CLASS

  • endogenous catecholamine

MECHANISM OF ACTION

  • direct alpha and beta adrenergic receptor agonist (vasopressor and weak inotropes)
  • alpha > beta
  • alpha effects:
    — increased SVR -> increased afterload; increased DBP and coronary perfsuion pressure
    — increased venoconstriction -> increased venous return -> increased preload
  • beta effects:
    — inotropy and chronotropy

PHARMACEUTICS

  • clear, colourless solution, 2mg/mL, norepinephrine bitartrate

DOSE

  • 0.1 to 1 mcg/kg/min IV via central line

INDICATIONS

  • hypotension refractory to fluid resuscitation (primarily distributive shock such as septic shock, neurogenic shock, post-bypass vasoplegia and drug-induced)

ADVERSE EFFECTS

  • hypertension
  • reflex bradycardia
  • hyperglycaemia
  • increased afterload and beta effects may increased myocardial work and oxygen consumption
  • peripheral ischaemia

PHARMACOKINETICS

  • Absorption – IV (preferably via CVL)
  • Distribution – small Vd
  • Metabolism – MAO and COMT
  • Elimination – short t1/2, unchanged in urine

Evidence

  • Cochrane Review 2011

–  23 RCT’s
– n = 3212
– 6 different vasopressors (alone or in combination with dobutamine or dopexamine)
-> dopamine: increased risk of arrhythmias
-> no significant evidence to say that one is better than the other

  • VAAST Trial 2008 NEJM

– DB MC RCT
– n = 780
– Vasopressin vs noradrenaline
– Patients on low dose Norad randomised to Vasopressin vs Norad
-> no significant difference in mortality @ 28 days

  • CAT Study, 2009 Int Care Med

– Australasian MC DB RCT
–  Noradrenaline vs Adrenaline to treat hypotension (sepsis or cardiogenic failure)
– n = 208
-> no significant difference in mortality, LOS, ventilation, shock duration
-> adrenaline – transient lactic acidosis, hyperglycaemia, tachycardia

  • Annane et al, 2007 Lancet

– MC RCT
– n = 330
– noradrenaline vs adrenaline in Septic Shock
-> no significant difference: mortality, BP, time to haemodynamic stability, duration of vasopressor therapy, time to organ dysfunction resolution, adverse effects
-> criticisms = underpowered, methodology suboptimal, strict inclusion criteria

  • Martin et al, 2000 CCM

– effect of norepinephrine on the outcome of septic shock
– n = 97 adults septic shock
– low dose dopamine then randomized to high dose dopamine vs noradrenaline
– adrenaline added if non-responding
-> use of noradrenaline strongly related (p<0.001) to favorable outcome considered protective, markedly decreased hospital mortality
-> Splanchnic function not worsened by NA

References and Links

Journal articles

  • Myburgh J. Norepinephrine: more of a neurohormone than a vasopressor. Crit Care. 2010;14(5):196. doi: 10.1186/cc9246. Epub 2010 Sep 20. Review. PubMed PMID:  20860853 ; PubMed Central PMCID: PMC3219251 .
  • Myburgh JA. An appraisal of selection and use of catecholamines in septic shock – old becomes new again. Crit Care Resusc. 2006 Dec;8(4):353-60. Review. PubMed PMID: 17227275. [Free Full Text]

FOAM and web resources

  • Resus.ME — Norepinephrine increases preload (2011)

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