Standard Concentration of Norepinephrine for IV Administration
The standard adult concentration of norepinephrine for intravenous administration is 4 mg of norepinephrine added to 250 mL of D5W to yield a concentration of 16 μg/mL. 1
Preparation Guidelines
- For adults, the standard concentration is prepared by adding 4 mg of norepinephrine to 250 mL of D5W to create a 16 μg/mL solution (also referred to as a 1:250,000 solution) 2, 1
- For anaphylaxis, an alternative concentration can be prepared by adding 1 mg of norepinephrine to 100 mL of saline to create a 1:100,000 solution (10 μg/mL) 2, 1
- 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 μg/kg/min 2, 1
Administration Considerations
- Central venous access is preferred for administration of norepinephrine to minimize risk of extravasation 1, 3
- If central access is unavailable or delayed, peripheral IV administration can be used temporarily with strict adherence to protocols 1, 4
- For peripheral administration, use proper site selection and monitor frequently for signs of extravasation 3, 4
Infusion Rates and Titration
- Standard infusion rates for adults typically range from 1 to 4 μg/min (15-60 drops per minute with a microdrop apparatus), increasing to a maximum of 10.0 μg/min for adults and adolescents 2
- For pediatric patients, typical dosing ranges from 0.1-1.0 μg/kg per minute, starting at the lowest dose and titrating to desired clinical effect 2, 1
- Doses as high as 5 μg/kg per minute are sometimes necessary in children 2, 1
Stability and Storage
- Norepinephrine solutions at concentrations of 4 μg/mL and 16 μg/mL are chemically stable for seven days at room temperature under ambient light when diluted in either D5W or NS 5
- After 7 days, solutions maintain 95.7-104.5% of their original concentration 5
Monitoring and Safety Precautions
- Monitor blood pressure and heart rate every 5-15 minutes during initial titration 1
- If extravasation occurs, infiltrate 5-10 mg of phentolamine diluted in 10-15 mL of saline into the site as soon as possible to prevent tissue necrosis 1, 4
- 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 can counteract dermal vasoconstriction 2, 1
- Do not mix norepinephrine with sodium bicarbonate or other alkaline solutions in the IV line, as they can inactivate the medication 1
Clinical Efficacy
- Norepinephrine has been shown to be effective in preventing post-induction hypotension and may reduce postoperative complications in major abdominal surgery 6
- Studies comparing epinephrine and norepinephrine have shown no significant difference in achieving mean arterial pressure goals in critically ill patients 7
Remember that while peripheral administration of norepinephrine is possible for short durations (<24 hours) and at lower doses, central venous access remains the preferred route for longer-term administration to minimize the risk of extravasation and tissue injury.