How do I initiate a norepinephrine (vasopressor) drip?

How to Start a Norepinephrine Drip

Norepinephrine should be administered through a central venous line at an initial dose of 0.05-0.1 mcg/kg/min, titrated every 5 minutes to achieve a target mean arterial pressure (MAP) of 65 mmHg. 1

Preparation and Administration

• Norepinephrine requires central venous access for administration, with continuous arterial blood pressure monitoring via an arterial line whenever possible 1
• Standard concentration: Mix 4 mg norepinephrine in 250 mL D5W or normal saline (16 mcg/mL) 1
• Alternative concentration for fluid restriction: Mix 8 mg norepinephrine in 250 mL (32 mcg/mL) 1
• Use an infusion pump for precise administration 1
• Initial dose: 0.05-0.1 mcg/kg/min, titrated to achieve target MAP of 65 mmHg 1, 2
• Titration: Increase by 0.05-0.1 mcg/kg/min every 5 minutes until target MAP is achieved 1

Monitoring and Titration

• Place an arterial line as soon as practical for continuous blood pressure monitoring 2, 1
• Target MAP: 65 mmHg for most patients 2
• Higher MAP targets (70-80 mmHg) may be appropriate for patients with chronic hypertension 2
• Monitor for signs of adequate tissue perfusion: urine output, mental status, capillary refill, skin temperature, and lactate clearance 2
• Titrate dose based on hemodynamic response, typically 0.05-0.5 mcg/kg/min 2, 1

Management of Refractory Hypotension

• If target MAP cannot be achieved with maximum doses of norepinephrine, consider adding:
  • Vasopressin 0.03 units/minute (not to exceed 0.04 units/minute unless as salvage therapy) 2, 1
  • Epinephrine as a second-line agent 2
  • Dobutamine (up to 20 mcg/kg/min) if myocardial dysfunction is present 2

Important Considerations and Precautions

• Ensure adequate fluid resuscitation before or concurrent with norepinephrine initiation 2, 3
• For profound, life-threatening hypotension (diastolic BP ≤ 40 mmHg), consider starting norepinephrine simultaneously with fluid resuscitation 3
• Monitor for extravasation if administered peripherally (central line strongly preferred) 1
• Phenylephrine is not recommended except in specific circumstances (e.g., norepinephrine-associated arrhythmias) 2
• Dopamine should only be used in highly selected patients with low risk of tachyarrhythmias or bradycardia 2, 1
• Earlier addition of vasopressin (within 3 hours of starting norepinephrine) may lead to faster shock resolution 4

Weaning Protocol

• Once the patient is hemodynamically stable, gradually taper norepinephrine by 0.05 mcg/kg/min every 15-30 minutes while monitoring MAP 1
• If MAP falls below target, return to previous effective dose and attempt weaning later 1
• If multiple vasopressors are used, typically wean vasopressin last 1, 4