What is the ideal starting dose of norepinephrine (vasopressor) drip in micrograms per kilogram per minute (mcg/kg/min)?

Ideal Starting Dose of Norepinephrine Drip

The ideal starting dose of norepinephrine drip is 0.1-0.5 mcg/kg/min for adults with severe hypotension or shock. 1

Dosing Guidelines by Patient Population

Adults

• Initial dose range: 0.1-0.5 mcg/kg/min 1
• For a 70 kg adult, this translates to approximately 7-35 mcg/min
• For persistent hypotension after 10 minutes, consider increasing to 0.05-0.5 mcg/kg/min 1

Special Situations

• Septic shock: Starting at 0.05 μg/kg/min may be appropriate when administered early, simultaneously with fluid resuscitation 2
• Obese patients: May require lower weight-based doses (approximately 0.09 μg/kg/min) but similar absolute doses compared to non-obese patients 3

Administration Considerations

Preparation and Delivery

• Administer through a secure, preferably central intravenous line
• Continuous infusion pump is essential for accurate delivery
• Monitor blood pressure every minute during initial titration

Titration Strategy

1. Begin at the recommended starting dose
2. Assess response after 2-5 minutes
3. If inadequate response, increase dose incrementally
4. Target systolic blood pressure >90 mmHg or mean arterial pressure >75 mmHg 4

Clinical Considerations and Cautions

Potential Adverse Effects

• Local ischemia and ulceration (if extravasation occurs)
• Tachycardia and tachyarrhythmias
• Hypertension
• Metabolic changes (hyperglycemia, increased lactate, hypokalemia) 1

Important Precautions

• Relative contraindication: Hypovolemia - ensure adequate volume resuscitation before or concurrent with norepinephrine initiation
• May increase myocardial oxygen requirements - use cautiously in patients with ischemic heart disease
• Can cause renal and mesenteric vasoconstriction 1

Refractory Hypotension Management

If hypotension persists despite adequate norepinephrine dosing:

1. Escalate norepinephrine dose by doubling the bolus dose 1
2. Consider adding vasopressin (1-2 IU bolus with or without infusion) 1
3. Consider glucagon (1-2 mg IV) if patient is on beta-blockers 1
4. Ensure adequate fluid resuscitation (up to 20-30 ml/kg) 1

Monitoring Parameters

• Continuous blood pressure monitoring
• Heart rate and ECG
• Urine output
• Peripheral perfusion
• Lactate levels to assess tissue perfusion

Norepinephrine is the preferred vasopressor for most shock states, particularly septic shock, as it has been shown to have fewer adverse effects compared to dopamine, which is associated with more arrhythmic events 5.