What is an alternative to D5W (5% dextrose solution) for diluting norepinephrine?

Alternative Diluents for Norepinephrine

Normal saline (0.9% sodium chloride) is an equally effective and stable alternative to D5W for diluting norepinephrine, with both solutions maintaining chemical stability for up to 7 days at room temperature. 1, 2

Standard Dilution Options

Both D5W and normal saline are acceptable diluents for norepinephrine preparation:

• Standard concentration with D5W: Add 4 mg norepinephrine to 250 mL D5W to yield 16 μg/mL 3
• Standard concentration with normal saline: Add 4 mg norepinephrine to 250 mL NS to yield 16 μg/mL 3
• Alternative concentration for anaphylaxis: Add 1 mg norepinephrine to 100 mL saline to create a 1:100,000 solution (10 μg/mL), administered at 30-100 mL/h 3

Stability Evidence

The choice between D5W and normal saline does not affect norepinephrine stability:

• Both D5W and NS maintain >95% of initial norepinephrine concentration after 7 days at room temperature under ambient light 1
• At 4°C with light protection, solutions remain stable for up to 61 days in either diluent 2
• No statistically significant difference exists between D5W and NS regarding chemical stability (P = 0.06) 2

Clinical Considerations for Diluent Selection

Normal saline may be preferable in certain clinical scenarios:

• Septic shock management: Crystalloid solutions (including normal saline or balanced crystalloids) are recommended for concurrent fluid resuscitation, making NS a logical choice for both volume replacement and vasopressor dilution 3
• Avoiding dextrose-related complications: NS eliminates concerns about hyperglycemia in critically ill patients or diabetic patients
• Compatibility with fluid resuscitation protocols: The Surviving Sepsis Campaign recommends minimum 30 mL/kg crystalloid boluses before or concurrent with norepinephrine initiation 3

Important Compatibility Warning

Never mix norepinephrine with sodium bicarbonate or other alkaline solutions, as adrenergic drugs are inactivated in alkaline solutions 3

Pediatric Dilution Alternative

For pediatric patients, the "rule of 6" provides a simplified saline-based approach: multiply 0.6 × body weight (kg) to determine milligrams of norepinephrine, then dilute to 100 mL of saline; 1 mL/h then delivers 0.1 mcg/kg/min 3

Storage Recommendations

• Solutions protected from light at 4°C remain stable for 61 days in either diluent 2
• Room temperature storage (23°C) with ambient light exposure: both diluents stable for at least 7 days 1
• Light-exposed solutions retain 90% concentration after 39 days at 4°C 2