How do you administer a norepinephrine drip?

Norepinephrine Drip Administration Protocol

Norepinephrine should be administered as a continuous infusion starting at 0.5 mg/h (approximately 0.1 μg/kg/min) and titrated up to 3 mg/h based on patient response, with the goal of increasing mean arterial pressure by 10 mmHg or achieving urine output >50 mL/h. 1

Preparation and Dosing

• Standard adult concentration: Add 4 mg (4 mL of 1 mg/mL solution) of norepinephrine to 250 mL of D5W to yield a concentration of 16 μg/mL 1
• Alternative concentration for anaphylaxis: Add 1 mg (1 mL) of norepinephrine to 100 mL of saline to create a 1:100,000 solution (10 μg/mL), administered at 30-100 mL/h (5-15 μg/min) 1
• For pediatric patients, use the "rule of 6": 0.6 × body weight (kg) = number of milligrams diluted to total 100 mL of saline; then 1 mL/h delivers 0.1 μg/kg/min 2
• Pediatric dosing typically ranges from 0.1-1.0 μg/kg/min, starting at the lowest dose and titrating to desired clinical effect 2

Administration Route

• Central venous access is preferred for administration of norepinephrine 1, 3
• If central access is unavailable or delayed, peripheral IV or intraosseous administration can be used temporarily 1, 4
• For peripheral administration, use a large bore vein with adequate blood flow 4, 3
• Peripheral administration should be limited to low doses and short duration (<24 hours) when possible 4

Monitoring and Titration

• Monitor blood pressure and heart rate every 5-15 minutes during initial titration 1
• Titrate dose to achieve target mean arterial pressure (typically 10 mmHg above baseline) or adequate tissue perfusion 1
• For septic shock, target normalization of capillary refill (≤2 seconds) and age-appropriate heart rate 1
• Increase dose by 0.5 mg/h every 4 hours as needed, to a maximum of 3 mg/h 1
• Monitor for signs of excessive vasoconstriction (cold extremities, decreased urine output) 1

Precautions and Complications

• Check IV site every 2 hours for signs of extravasation when administering peripherally 4, 3
• If extravasation occurs, administer 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 2, 3
• Local nitroglycerin paste can also be applied to the extravasation site to prevent tissue ischemia 3
• Watch for potential side effects including hypertension, arrhythmias, and tissue ischemia 1, 5
• Ensure adequate volume resuscitation before and during norepinephrine administration to optimize cardiac output 1

Special Considerations

• In pediatric septic shock, higher doses up to 2.5 μg/kg/min may be necessary 5
• For anaphylaxis, norepinephrine should only be used in cases not responding to epinephrine injections and volume resuscitation 1
• In patients with cirrhosis and hepatorenal syndrome, norepinephrine has shown similar efficacy to terlipressin in improving renal function 1
• For cesarean delivery under spinal anesthesia, lower doses of 1-2 μg/min may be sufficient to prevent hypotension 6

Remember that continuous hemodynamic monitoring is essential when administering intravenous norepinephrine, particularly at higher doses 1.