Norepinephrine Administration via Intraosseous Line
Yes, norepinephrine can be safely administered through an intraosseous (IO) line at low dosages, particularly when central venous access is not immediately available. This approach is explicitly supported by current resuscitation guidelines and is comparable in efficacy to intravenous routes.
Guideline Support for IO Administration
The Surviving Sepsis Campaign (2020) explicitly states that epinephrine or norepinephrine may be administered through a peripheral vein or intraosseous line if central venous access is not readily accessible, particularly after 40-60 mL/kg of fluid resuscitation in children with septic shock 1
The American Heart Association (2010) confirms that all intravenous medications can be administered intraosseously, including catecholamines, with onset of action and drug levels comparable to venous administration 1
The Society of Critical Care Medicine acknowledges that if central access is unavailable or delayed, peripheral IV or intraosseous administration can be used temporarily 2
Evidence Supporting Safety and Efficacy
Animal studies demonstrate that IO administration of emergency drugs including epinephrine is comparable to central and peripheral IV routes, with equivalent magnitudes of peak effect and equal or longer durations of action 3
The IO route has been validated for all emergency drugs and solutions, with time to needle placement averaging 60 seconds or less with experience 3
Complications from IO access occur in less than 1% of cases, and the technique is simple to learn 4
Practical Administration Protocol
When using IO access for norepinephrine:
Start at 0.1-0.5 mcg/kg/min (approximately 7-35 mcg/min in a 70 kg adult) and titrate to achieve a mean arterial pressure of 65 mmHg 2
Follow each medication with a saline flush to promote entry into the central circulation 1
Use manual pressure or an infusion pump to administer the infusion, as IO access may require additional pressure for adequate flow 1
Monitor blood pressure every 5-15 minutes during initial titration 2
Transition to central venous access as soon as practical for longer-term administration, though IO can be used safely for the duration needed in emergency situations 1
Critical Considerations
Ensure adequate volume resuscitation (minimum 30 mL/kg crystalloid bolus) before or concurrent with norepinephrine initiation, as vasoconstriction in hypovolemic patients causes severe organ hypoperfusion 2
IO access is particularly valuable in cardiac arrest and emergency situations where IV access will be critically delayed 3, 4
Blood samples can be obtained through IO access for analysis including type and cross-match, though acid-base analysis is inaccurate after sodium bicarbonate administration via the IO cannula 1
Duration and Dose Limitations
While guidelines support IO use for emergency vasopressor administration, plan for central line placement if norepinephrine will be needed beyond the initial resuscitation period 1, 2
Low-dose norepinephrine (<0.5 mcg/kg/min) can be safely administered peripherally or via IO for up to 24 hours based on peripheral administration protocols, though central access remains preferred for higher doses or prolonged use 5, 6