• This guideline is only for the use in adult patients who have been accepted for admission to ICU and with a critical care outreach nurse prior to transfer.

• The decision to commence peripheral noradrenaline should be made by an ICU consultant.

• 4mg Noradrenaline made up to a total of 246mL with 0.9 % sodium chloride.

• See Appendix for dosing guideline.

• Maximum dose 0.3micrograms/kg/min.

• Patient’s cannula sight must be closely monitored for extravasation.

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition.

Print copies must be destroyed after use.

Abbreviations

This document provides guidance to adult critical care professionals on the administration of noradrenaline via a peripheral venous cannula (PVC) to adult critical care patients who have been reviewed by the intensive care/critical care outreach team and been accepted for admission to ICU.

• This guideline is only for use in adult patients in ICU and those accepted for admission to ICU accompanied by a critical care outreach nurse prior to transfer. The decision to commence peripheral noradrenaline can be made by an ICU doctor.

• To be commenced when the MAP is below the number indicated by the ICU doctor (this will be a patient dependent value).

• To preferentially replace other peripherally administered vasopressors, e.g., phenylephrine & metaraminol, as first line therapy.

• Organ dysfunction not otherwise expected to require a central line.

• Appropriate dedicated peripheral access available for infusion, and second cannula in place.

• Invasive arterial monitoring in situ, place an NIBP on a different limb to the noradrenaline infusion and set to cycle every 5 minutes. Once blood pressure has stabilised, reduce the frequency in discussion with ICU medical team.

• Central line or PICC in place.

• Unable to site appropriate peripheral access.

• Anticipated to need vasopressors for >72hrs.

• Patient is fluid restricted and infusion rate adversely affects fluid and/or electrolyte balance,

• Patients must have a 20G (pink) cannula, in the largest vein possible.

• This must be placed in the upper limbs and be easily observable.

• It must flush easily without pain or visible extravasation.

• Clear cannula dressing should be in situ.

• No Bionectar or octopus should be connected.

• There should be no blood pressure cuff on the same limb as the cannula running the peripheral noradrenaline infusion.

• Check and document infusion site every 2 hours for free flow and blanching. If patient is not responding then check line, pump and site.

• If there is any concern regarding the patency of the cannula, then the infusion should be discontinued, and rescue measures instituted.

• 4mg Noradrenaline made up to a total of 246mL with 0.9 % sodium chloride.

• Maximum dose 0.3micrograms/kg/min.

• If weight greater than 100kg, use rate for 100kg.

• Medical team on unit to be contacted for review if dose > 0.2micrograms/kg/min.

• To be used for less than 72hours.

• A patient weight must be recorded on EPIC before prescribing.

• Prescribe peripheral noradrenaline (infusion rates will generate if weight recorded prior).

• Peripheral Noradrenaline sticker must be attached to dedicated infusion line.

• Establish blood pressure targets for therapy.

• Confirm peripheral access meets the criteria above.

• Complete the VIP score flowsheet.

• If VIP score ≥ 1, immediately inform ICU doctor and record hourly.

• The outreach nurse must remain with the patient if outside of ICU.

• If not used for 2 - 4 hours, disconnect giving set.

• Flush with 10mLs 0.9% sodium chloride slowly over 1 minute.

• The PVC can now be used for other intravenous therapies.

1. Stop the infusion immediately if signs of extravasation are apparent (VIP score ≥ 1). Including if the patient complains of a burning sensation or pain.

2. Alert ICU doctor and record VIP score hourly.

3. Consider where Noradrenaline should be recommenced e.g. via second IV line/ central line.

4. Demarcate area of skin change.

5. The catheter should not be removed but should be left in place to attempt aspiration 3-5ml of fluid from the extravasated area.

6. DO NOT flush the cannula.

7. If phentolamine available, then follow the guidance below:

8. Remove cannula.

9. Demarcate area of skin change.

10. Apply 2.5cm of GTN 0.4% (rectal) ointment, repeat after 8 hours if needed.

11. Elevate the affected limb.

12. Apply warm/hot compress for 20mins, four times a day (per Trust Extravasation guideline).

13. Refer to Tissue Viability and IVAS if skin damage develops.

14. Consider referring to Plastics if severe.

15. Complete an incident report (Inphase).

• GTN 0.4% rectal ointment: Omnicell

• Phentolamine 10mg/1mL injection (ULM): Omnicell Fridge

• Intensive Care Society (2022) Guidance for: the use of vasopressor agents by peripheral intravenous infusion in adult critical care patients: version 1.1. Available at: https://ics.ac.uk/resource/peripheral-vasopressor-guide.html (Accessed: 15 July 2024).

• Leeds Teaching Hospitals NHS Trust (2023) Peripherally administered vasopressor guideline for critical care.

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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