Lecture on Norepinephrine in Critical Care

all right in this lesson we're going to talk about one of the most widely used medications in critical care and one that really plays a very important role in the care that we can deliver to our patients with that said let's go and get started talking about norepinephrine [Music] all right you guys welcome back to another video lesson from icu advantage my name is eddie watson my goal here is to try to give you guys the confidence to succeed in the icu by taking these complex critical care subjects and making them easy to understand i truly hope that i'm able to do just that and if i am i do invite you to subscribe to the channel below make sure you hit that bell icon though and select all notifications that way you never miss out when i release a new lesson also don't forget that the notes for this lesson as well as all the previous lessons are available to the youtube and patreon members you can find links to both of those down below as well as if you'd be interested in supporting me and this channel you can also find a link down below where you can pick up an icu advantage sticker show your support while also helping the channel to to grow into the vision that i see for it and then finally at the end of this lesson make sure and head on over to icuadvantage.com to test your knowledge on this subject take a quiz a free online quiz as well as be entered into a weekly gift card giveaway again you'll find a link to that down in the description below alright so with that out of the way let's go and get started with our lesson and let's start off talking about what exactly is norepinephrine so norepinephrine also known as norepi or by its trade name levafed as well as outside the united states it's often referred to as noradrenaline now this medication is the same as the natural hormone and neurotransmitter that we actually have inside of our bodies now when we give this to our patients we're actually reproducing the effects of the hormone now it is considered a sympathemetric medication meaning that it mimics the effects of the natural endogenous hormone on the sympathetic nervous system the main purpose is to increase our patient's blood pressure and thus we classify it as a vasopressor so how exactly is it that norepinephrine works so the way that it works is by activating various receptors that are a part of the sympathetic nervous system now typically these are activated through the endogenous release of the hormone in the body but when we give this medication to our patient it actually works primarily by activating our alpha and beta adrenergic receptors and with our alpha receptors we actually see effects on both alpha 1 and alpha 2 receptors now there are several effects of these receptors being activated but primarily we're looking for the effect on smooth muscle contraction both in our arteries and our veins and in fact the impact to the arteries and the veins seems to be about equal with this now by activating these receptors we achieve the vasoconstriction and the goal here is to increase our patient's systemic vascular resistance and thus increasing their blood pressure now with our beta receptors we also see effects on our beta 1 beta 2 and beta 3 receptors although the beta 3 receptor i'm really not going to talk about for beta 1 the activation of this receptor actually has many effects but the primary effects here are actually going to be on the heart so we see both an increase in our patient's heart rate so this is going to be a positive chronotropic effect as well as increases in contractility giving it a positive inotropic effect so this leads to an increase in our patient's cardiac output which can also increase our patient's blood pressure as well now for beta 2 activation it has its primary effects with smooth muscle relaxation and most notably this relaxation is going to be of the airways it can also lead to dilation of arteries that go to skeletal muscle the coronary arteries as well as the hepatic artery as well and so the result of the full activation of these receptors is really to increase our patient's blood pressure and so we should see things like increases in our svr our pvr our pulmonary artery occlusive pressure our patients map their cvp and then heart rate and cardiac output as well now remember though that the beta 1 activation in patients who are already tachycardic can lead to rates that are sometimes too fast and thus this can actually decrease our cardiac output because of them not having enough time for filling between each contraction also another important thing to note is that the affinity of norepinephrine to bind to those receptors is actually impacted by things such as the concentration of the medication our patient's temperature as well as their ph and this is important to know because oftentimes our critically ill patient is going to be in an acidotic state and so acidosis in particular can thus reduce the effectiveness of this medication all right so now let's move on and talk about the dosing so norepi has a relatively short half-life of just two and a half minutes and thus when we give this medication we're going to be giving it as a continuous iv infusion now the preferred site for the infusion is going to be via a central line but we can also give it via peripheral iv we would want ideally a large vein such as the ac if we're going to be using this via an iv and typically you know we'll start this via an iv if we don't have a central line but then pretty quickly especially if the infusion is going to persist and we're going to keep this medication going we're going to really look to get a central line as soon as we can now for our formulation we're typically going to find norepi in concentrations of either 4 milligrams eight milligrams 16 milligrams or even 32 milligrams in 250 mls now this can either be in pre-mixed bags or container or it also can be manually prepared with the vials of norepi and this is typically found in a one milligram per ml concentration we would mix this up manually especially in emergency situations where we need to get this drip going pretty quickly now as for the dosing the the dosing ranges really vary from facility to facility but in general we're going to see ranges like 1 to 30 or 1 to 50 micrograms per minute now for weight-based dosing this again varies from facility to facility but typically can be in the range of 0.025 to 1 microgram per kilogram per minute now typically we're going to start the medication off at 5 to 10 micrograms per minute or 0.05 micrograms per kilogram per minute and then titration is really going to depend on the orders that you have and the facility that you work in but i do have some helpful pointers that i did cover in a previous lesson where i was talking about vasopressors when it comes to titration so i'll go ahead and link to that lesson up above here but next let's talk about some of the adverse effects of this medication and really the most common effect that we're going to be watching out for is going to be an excessive vasoconstriction and this vasoconstriction can actually lead to decreased perfusion of our patients and organs which obviously is going to be detrimental for them we can also see excessive hypertension as a result of this as well now tachycardia and potentially arrhythmias are the next most common effects that we can see with this medication and then sometimes we can actually see a baroreceptor mediated bradycardia and so here the increase in blood pressure that we would expect from this medication can actually activate the baroreceptors and typically this will happen and actually cancel out those beta-1 effects where we can potentially see an increase in our patient's heart rate but sometimes this baroreceptor activation can actually be overwhelming and lead to a bradycardia in our patients and then for patients that have pulmonary hypertension that increase in our pulmonary vascular resistance may actually have negative effects for them as well and then finally is really related to giving this medication via iv and that's going to be if we have an iv extravasation and so the extravasation of norepi out of the blood vessel and into the tissue can actually lead to tissue necrosis and thus this is why that center line is generally preferred finally like i typically do in these lessons i just want to talk about our uses for this medication and critical care and really the primary use is going to be for our patients who have hypotension and shock so because of its effects on both the vasoconstriction from the alpha receptor activation as well as the beta receptor cardiac effects norepinephrine is actually widely used in critical care as mentioned before the main goal is to increase our patient's systemic vascular resistance and thus our patients blood pressure and their map and our maps are really going to vary from patient to patient and kind of what's going on but generally we're going to try to maintain a map of at least 60 or 65. now most commonly we're going to be using this medication and distributive shock but we can use it in any shock state that said though in cardiogenic shock the increase in afterload may actually work against us and may not be indicated for them and then the last thing i really want to hit on is in the cases of sepsis and septic shock now yes this is a form of distributive shock but i did want to just really bring up that norepinephrine is actually the first line vasopressor that we're going to use in the treatment of sepsis and septic shock when the patient remains hypotensive following the fluid administration and this all comes from the guidelines from the surviving sepsis campaign and in those guidelines from them as well our map goal for these patients is going to be 65. all right so that was our review of norepinephrine or levofed noradrenaline whatever you refer to it as i really hope that you guys found this lesson useful that you've got some good information from this if you did please leave me a like down below leave me a comment let me know as well i enjoy reading the comments that you guys leave if you haven't already make sure and subscribe to the channel down below as well and a special shout out to the awesome youtube and patreon members out there the support that you guys are going to show me and this channel is truly appreciated now for the rest of you guys if you'd be interested in showing additional support for this channel you can join the youtube membership down below or head on over to patreon and check out some of the additional perks that you guys get for doing just that as well as down in the description i've got links to some awesome nursing gear as well as some pretty cool t-shirt designs down there as well make sure you guys stay tuned for the next lesson that i release otherwise in the meantime check out a couple awesome lessons i'm gonna link to right here as always thank you guys so much for watching have a great day

all right in this lesson we&#39;re going to talk about one of the most widely used medications in critical care and one that really plays a very important role in the care that we can deliver to our patients with that said let&#39;s go and get started talking about norepinephrine [Music] all right you guys welcome back to another video lesson from icu advantage my name is eddie watson my goal here is to try to give you guys the confidence to succeed in the icu by taking these complex critical care subjects and making them easy to understand i truly hope that i&#39;m able to do just that and if i am i do invite you to subscribe to the channel below make sure you hit that bell icon though and select all notifications that way you never miss out when i release a new lesson also don&#39;t forget that the notes for this lesson as well as all the previous lessons are available to the youtube and patreon members you can find links to both of those down below as well as if you&#39;d be interested in supporting me and this channel you can also find a link down below where you can pick up an icu advantage sticker show your support while also helping the channel to to grow into the vision that i see for it and then finally at the end of this lesson make sure and head on over to icuadvantage.com to test your knowledge on this subject take a quiz a free online quiz as well as be entered into a weekly gift card giveaway again you&#39;ll find a link to that down in the description below alright so with that out of the way let&#39;s go and get started with our lesson and let&#39;s start off talking about what exactly is norepinephrine so norepinephrine also known as norepi or by its trade name levafed as well as outside the united states it&#39;s often referred to as noradrenaline now this medication is the same as the natural hormone and neurotransmitter that we actually have inside of our bodies now when we give this to our patients we&#39;re actually reproducing the effects of the hormone now it is considered a sympathemetric medication meaning that it mimics the effects of the natural endogenous hormone on the sympathetic nervous system the main purpose is to increase our patient&#39;s blood pressure and thus we classify it as a vasopressor so how exactly is it that norepinephrine works so the way that it works is by activating various receptors that are a part of the sympathetic nervous system now typically these are activated through the endogenous release of the hormone in the body but when we give this medication to our patient it actually works primarily by activating our alpha and beta adrenergic receptors and with our alpha receptors we actually see effects on both alpha 1 and alpha 2 receptors now there are several effects of these receptors being activated but primarily we&#39;re looking for the effect on smooth muscle contraction both in our arteries and our veins and in fact the impact to the arteries and the veins seems to be about equal with this now by activating these receptors we achieve the vasoconstriction and the goal here is to increase our patient&#39;s systemic vascular resistance and thus increasing their blood pressure now with our beta receptors we also see effects on our beta 1 beta 2 and beta 3 receptors although the beta 3 receptor i&#39;m really not going to talk about for beta 1 the activation of this receptor actually has many effects but the primary effects here are actually going to be on the heart so we see both an increase in our patient&#39;s heart rate so this is going to be a positive chronotropic effect as well as increases in contractility giving it a positive inotropic effect so this leads to an increase in our patient&#39;s cardiac output which can also increase our patient&#39;s blood pressure as well now for beta 2 activation it has its primary effects with smooth muscle relaxation and most notably this relaxation is going to be of the airways it can also lead to dilation of arteries that go to skeletal muscle the coronary arteries as well as the hepatic artery as well and so the result of the full activation of these receptors is really to increase our patient&#39;s blood pressure and so we should see things like increases in our svr our pvr our pulmonary artery occlusive pressure our patients map their cvp and then heart rate and cardiac output as well now remember though that the beta 1 activation in patients who are already tachycardic can lead to rates that are sometimes too fast and thus this can actually decrease our cardiac output because of them not having enough time for filling between each contraction also another important thing to note is that the affinity of norepinephrine to bind to those receptors is actually impacted by things such as the concentration of the medication our patient&#39;s temperature as well as their ph and this is important to know because oftentimes our critically ill patient is going to be in an acidotic state and so acidosis in particular can thus reduce the effectiveness of this medication all right so now let&#39;s move on and talk about the dosing so norepi has a relatively short half-life of just two and a half minutes and thus when we give this medication we&#39;re going to be giving it as a continuous iv infusion now the preferred site for the infusion is going to be via a central line but we can also give it via peripheral iv we would want ideally a large vein such as the ac if we&#39;re going to be using this via an iv and typically you know we&#39;ll start this via an iv if we don&#39;t have a central line but then pretty quickly especially if the infusion is going to persist and we&#39;re going to keep this medication going we&#39;re going to really look to get a central line as soon as we can now for our formulation we&#39;re typically going to find norepi in concentrations of either 4 milligrams eight milligrams 16 milligrams or even 32 milligrams in 250 mls now this can either be in pre-mixed bags or container or it also can be manually prepared with the vials of norepi and this is typically found in a one milligram per ml concentration we would mix this up manually especially in emergency situations where we need to get this drip going pretty quickly now as for the dosing the the dosing ranges really vary from facility to facility but in general we&#39;re going to see ranges like 1 to 30 or 1 to 50 micrograms per minute now for weight-based dosing this again varies from facility to facility but typically can be in the range of 0.025 to 1 microgram per kilogram per minute now typically we&#39;re going to start the medication off at 5 to 10 micrograms per minute or 0.05 micrograms per kilogram per minute and then titration is really going to depend on the orders that you have and the facility that you work in but i do have some helpful pointers that i did cover in a previous lesson where i was talking about vasopressors when it comes to titration so i&#39;ll go ahead and link to that lesson up above here but next let&#39;s talk about some of the adverse effects of this medication and really the most common effect that we&#39;re going to be watching out for is going to be an excessive vasoconstriction and this vasoconstriction can actually lead to decreased perfusion of our patients and organs which obviously is going to be detrimental for them we can also see excessive hypertension as a result of this as well now tachycardia and potentially arrhythmias are the next most common effects that we can see with this medication and then sometimes we can actually see a baroreceptor mediated bradycardia and so here the increase in blood pressure that we would expect from this medication can actually activate the baroreceptors and typically this will happen and actually cancel out those beta-1 effects where we can potentially see an increase in our patient&#39;s heart rate but sometimes this baroreceptor activation can actually be overwhelming and lead to a bradycardia in our patients and then for patients that have pulmonary hypertension that increase in our pulmonary vascular resistance may actually have negative effects for them as well and then finally is really related to giving this medication via iv and that&#39;s going to be if we have an iv extravasation and so the extravasation of norepi out of the blood vessel and into the tissue can actually lead to tissue necrosis and thus this is why that center line is generally preferred finally like i typically do in these lessons i just want to talk about our uses for this medication and critical care and really the primary use is going to be for our patients who have hypotension and shock so because of its effects on both the vasoconstriction from the alpha receptor activation as well as the beta receptor cardiac effects norepinephrine is actually widely used in critical care as mentioned before the main goal is to increase our patient&#39;s systemic vascular resistance and thus our patients blood pressure and their map and our maps are really going to vary from patient to patient and kind of what&#39;s going on but generally we&#39;re going to try to maintain a map of at least 60 or 65. now most commonly we&#39;re going to be using this medication and distributive shock but we can use it in any shock state that said though in cardiogenic shock the increase in afterload may actually work against us and may not be indicated for them and then the last thing i really want to hit on is in the cases of sepsis and septic shock now yes this is a form of distributive shock but i did want to just really bring up that norepinephrine is actually the first line vasopressor that we&#39;re going to use in the treatment of sepsis and septic shock when the patient remains hypotensive following the fluid administration and this all comes from the guidelines from the surviving sepsis campaign and in those guidelines from them as well our map goal for these patients is going to be 65. all right so that was our review of norepinephrine or levofed noradrenaline whatever you refer to it as i really hope that you guys found this lesson useful that you&#39;ve got some good information from this if you did please leave me a like down below leave me a comment let me know as well i enjoy reading the comments that you guys leave if you haven&#39;t already make sure and subscribe to the channel down below as well and a special shout out to the awesome youtube and patreon members out there the support that you guys are going to show me and this channel is truly appreciated now for the rest of you guys if you&#39;d be interested in showing additional support for this channel you can join the youtube membership down below or head on over to patreon and check out some of the additional perks that you guys get for doing just that as well as down in the description i&#39;ve got links to some awesome nursing gear as well as some pretty cool t-shirt designs down there as well make sure you guys stay tuned for the next lesson that i release otherwise in the meantime check out a couple awesome lessons i&#39;m gonna link to right here as always thank you guys so much for watching have a great day

Transcript for:Lecture on Norepinephrine in Critical Care

Transcript for:
Lecture on Norepinephrine in Critical Care