What is the maximum dose of noradrenaline (norepinephrine) that can be administered via a peripheral intravenous (IV) line?

Maximum Dose of Noradrenaline via Peripheral Line

Noradrenaline can be safely administered via peripheral IV line at doses up to 0.2-0.4 μg/kg/min for less than 24 hours, with most protocols recommending a maximum of 0.5 mg/h (approximately 0.1-0.15 μg/kg/min in a 70 kg adult) as the upper limit for peripheral administration. 1, 2

Recommended Dose Limits for Peripheral Administration

The safest approach is to limit peripheral noradrenaline to ≤0.2 μg/kg/min, which corresponds to "low-dose" noradrenaline and minimizes extravasation risk while maintaining efficacy. 1, 3

Specific Dose Thresholds:

• Maximum recommended dose: 0.2 μg/kg/min (approximately 14 μg/min or 0.84 mg/h in a 70 kg adult) 3
• Alternative conservative limit: 0.5 mg/h (approximately 8-12 μg/min or 0.1-0.15 μg/kg/min) 1
• Duration limit: Less than 24 hours of peripheral infusion 2, 4

The rationale for the 0.2 μg/kg/min cutoff is based on mortality data showing this represents the threshold between low and intermediate-dose noradrenaline, with doses above this level associated with significantly higher mortality (26.4% vs 14.0%) and greater hemodynamic instability. 3

Protocol Requirements for Safe Peripheral Administration

Mandatory Safety Elements:

• IV catheter specifications: Use ≥20-gauge catheter in large veins (antecubital fossa preferred over hand/wrist) 2, 4
• Site inspection frequency: Visual inspection and blood return assessment every 2 hours 2
• Adequate number of PIVs: Maintain at least 2 functional peripheral lines 2
• Maximum infusion duration: Transition to central line if noradrenaline needed >24 hours 2, 4

Extravasation Management Protocol:

If extravasation occurs, immediately infiltrate phentolamine 5-10 mg diluted in 10-15 mL of 0.9% sodium chloride intradermally at the site to prevent tissue necrosis. 5, 1, 6

• Pediatric phentolamine dose: 0.1-0.2 mg/kg up to 10 mg 5, 1
• Apply nitroglycerin paste topically as adjunctive therapy 6

Clinical Evidence Supporting Peripheral Administration

Recent high-quality prospective studies demonstrate peripheral noradrenaline is safe when protocols are followed:

• Extravasation rate: 2-2.2% in adult studies, with no cases requiring surgical intervention 4, 6
• 51.6% of patients receiving peripheral noradrenaline never required central line insertion, avoiding CVC-related complications 4
• Median CVC days avoided: 1 day per patient 4
• Pediatric extravasation rate: 2.2% with maximum noradrenaline dose of 0.2 μg/kg/min 7

When to Transition to Central Access

Convert peripheral to central venous access when:

• Noradrenaline dose exceeds 0.2 μg/kg/min (or 0.4 μg/kg/min as absolute maximum) 1, 3
• Infusion duration will exceed 24 hours 2, 4
• Inadequate peripheral access (unable to maintain 2 functional PIVs) 2
• Signs of extravasation or tissue injury develop 4, 6
• Patient requires escalation to intermediate or high-dose vasopressor support 3

Pediatric Considerations

For children, the same dose threshold of 0.2 μg/kg/min applies for peripheral administration. 7

• Typical pediatric range: 0.1-1.0 μg/kg/min (start at lowest dose) 5, 1
• Maximum doses up to 2.0 μg/kg/min may be necessary but require central access 5
• Doses as high as 5 μg/kg/min are sometimes needed in exceptional circumstances, mandating central line 5, 1

Critical Pitfalls to Avoid

• Never delay noradrenaline administration waiting for central access in severe hypotension (systolic <70 mmHg); start peripherally while arranging central line 1
• Do not mix noradrenaline with sodium bicarbonate or alkaline solutions in the same IV line, as catecholamines are inactivated 1
• Ensure adequate fluid resuscitation (minimum 30 mL/kg crystalloid bolus) before or concurrent with noradrenaline to prevent severe organ hypoperfusion from vasoconstriction in hypovolemic patients 1
• Avoid hand/wrist sites for peripheral noradrenaline; use antecubital or proximal forearm veins 2, 4

Practical Dosing Algorithm

For peripheral noradrenaline administration:

1. Start at 0.02-0.1 μg/kg/min (or 0.5 mg/h) via ≥20-gauge PIV in large vein 1
2. Titrate every 5-15 minutes targeting MAP ≥65 mmHg 1
3. If dose reaches 0.2 μg/kg/min and hypotension persists, arrange central line placement 1, 3
4. If dose must exceed 0.2 μg/kg/min before central access available, maximum peripheral dose is 0.4 μg/kg/min for shortest duration possible 3
5. Add vasopressin 0.03-0.04 units/min as second-line agent rather than escalating noradrenaline above 0.25 μg/kg/min 1