Maximum Dose of Noradrenaline (Norepinephrine)
The maximum dose of noradrenaline (norepinephrine) is 5 mcg/kg/min for pediatric patients, though typical dosing ranges from 0.1-1.0 mcg/kg/min. 1
Dosing Guidelines
Pediatric Patients
- Initial dosing should start at the lowest effective dose (0.1 mcg/kg/min) and titrate to desired clinical effect 1
- Typical maintenance dosing ranges from 0.1-1.0 mcg/kg/min 1
- Doses as high as 5 mcg/kg/min are sometimes necessary in children with refractory shock 1, 2
- A retrospective study of children with septic shock reported mean maximum doses of 2.5 ± 2.2 μg/kg/min, indicating that higher doses than typically recommended may be necessary in severe cases 2
Adult Patients
- Initial dose typically ranges from 8-12 mcg of base per minute (0.25-0.375 mL/min of standard concentration) 3
- Average maintenance dose ranges from 2-4 mcg of base per minute (0.0625-0.125 mL/min) 3
- Doses should be adjusted to establish and maintain a blood pressure sufficient to maintain vital organ perfusion (usually 80-100 mmHg systolic) 3
Severity Classification Based on Dose
Recent research has proposed classifying norepinephrine dosing into severity categories 4:
- Low dose: <0.2 μg/kg/min
- Intermediate dose: 0.2-0.4 μg/kg/min
- High dose: >0.4 μg/kg/min
These categories correlate with increasing hospital mortality rates, with high doses (>0.4 μg/kg/min) associated with significantly higher mortality 4.
Administration Considerations
Route of Administration
- Central venous access is preferred for administration of norepinephrine 1
- If central access is unavailable, peripheral IV or intraosseous routes can be used temporarily 1
- For pediatric patients, peripheral venous access or intraosseous routes have been used safely for short durations (median 3 hours) without adverse effects 2
Monitoring and Titration
- Monitor blood pressure and heart rate every 5-15 minutes during initial titration 1
- Titrate to achieve target mean arterial pressure or adequate tissue perfusion 1
- For septic shock, target normalization of capillary refill and age-appropriate heart rate 1
Complications and Precautions
- Extravasation can result in severe skin injury; 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 counteract dermal vasoconstriction 5
- High-dose norepinephrine therapy may be futile in patients with severe metabolic acidemia (bicarbonate levels <9.0 mEq/L) 6
- Potential side effects include ischemic injury, bradycardia, anxiety, transient headache, respiratory difficulty, and arrhythmias 3
- Ensure adequate volume resuscitation before and during norepinephrine administration to optimize cardiac output 1
Special Considerations
- For obese patients, weight-based dosing may result in overdosing; studies show obese patients require lower weight-based doses compared to non-obese patients (0.09 vs 0.13 μg/kg/min) 7
- Norepinephrine has been shown to be superior to dopamine in patients with cardiogenic shock, with fewer arrhythmic events 8
- The cause of shock and treatment with high-dose norepinephrine are not predictive of death, but severe disease and metabolic acidemia are associated with poor outcomes 6