Recommended Dilution Rate for Peripheral Noradrenaline Administration
For peripheral administration of noradrenaline (norepinephrine), the recommended dilution is 4 mg in 1,000 mL of 5% Dextrose Injection or Sodium Chloride Injection containing 5% dextrose, yielding a concentration of 4 mcg/mL. 1
Standard Dilution Protocol
- Add the content of one norepinephrine vial (4 mg in 4 mL) to 1,000 mL of 5% Dextrose Injection or Sodium Chloride Injection containing 5% dextrose to produce a 4 mcg/mL dilution 1
- Dextrose in the solution reduces loss of potency due to oxidation 1
- Administration in saline solution alone is not recommended 1
- Higher concentration solutions may be used in patients requiring fluid restriction 1
Administration Considerations
- Infuse norepinephrine into a large vein to minimize risk of extravasation 1
- Avoid infusions into the veins of the leg in elderly patients or those with occlusive vascular disease 1
- Avoid using a catheter-tie-in technique 1
- Prior to use, the diluted solution can be stored for up to 24 hours at room temperature (20°C to 25°C) and should be protected from light 1
Dosing Guidelines
- Initial dosage: 8 to 12 mcg per minute via intravenous infusion 1
- Typical maintenance dosage: 2 to 4 mcg per minute 1
- Monitor blood pressure every two minutes until desired hemodynamic effect is achieved, then every five minutes for the duration of the infusion 1
- When discontinuing the infusion, reduce the flow rate gradually to avoid abrupt withdrawal 1
Special Considerations for Peripheral Administration
- Peripheral infusions of norepinephrine can be a safe option in early resuscitation when following appropriate guidelines 2
- Using standard concentrations reduces the risk of errors 2
- 0.9% saline is recommended as the default diluent for peripheral norepinephrine 2
- Implementation of a protocol for peripheral administration can safely reduce central venous catheter use 3
Precautions and Monitoring
- Correct hypovolemia before initiating norepinephrine therapy 1
- Visually inspect the solution for particulate matter and discoloration prior to administration (solution should be colorless) 1
- Do not use if the solution is pinkish or darker than slightly yellow or if it contains a precipitate 1
- Monitor for signs of extravasation, which can result in severe skin injury 1
- Phentolamine (0.1-0.2 mg/kg up to 10 mg diluted in 10 mL of 0.9% sodium chloride) injected intradermally at the extravasation site may help counteract dermal vasoconstriction 4
Alternative Dilutions for Specific Situations
- For anaphylaxis requiring continuous infusion: An alternative 1:100,000 solution (1 mg in 100 mL saline) can be prepared and administered at an initial rate of 30 to 100 mL/h (5-15 mcg/min), titrated based on clinical response 4
- For pediatric patients: The "rule of 6" can be used - 0.6 × body weight (kg) = number of milligrams diluted to total 100 mL of saline; then 1 mL/h delivers 0.1 mcg/kg/min 4
Pediatric Considerations
- Pediatric dosing typically ranges from 0.1-1.0 mcg/kg per minute, starting at the lowest dose and titrating to desired clinical effect 4
- Doses as high as 5 mcg/kg per minute are sometimes necessary in children 4
- Studies suggest that peripheral administration of norepinephrine in children can be carried out without obvious complications when proper protocols are followed 2, 5