Can Norepinephrine Be Added to Dextrose Normal Saline (DNS)?
Yes, norepinephrine can and should be diluted in dextrose-containing solutions, including dextrose normal saline (DNS), as dextrose reduces loss of potency due to oxidation. 1
FDA-Approved Preparation Guidelines
The FDA label explicitly states the standard dilution protocol for norepinephrine: 1
- Add 4 mg of norepinephrine (one 4 mL vial) to 1,000 mL of 5% Dextrose Injection or Sodium Chloride solutions that contain 5% dextrose to produce a 4 mcg/mL concentration 1
- Dextrose is specifically recommended because it reduces loss of potency due to oxidation 1
- Administration in saline solution alone (without dextrose) is NOT recommended by the FDA 1
Alternative Concentrations for Fluid Restriction
- For patients requiring fluid restriction, use 8 mg norepinephrine in 250 mL of dextrose-containing solution (32 mcg/mL concentration) 2
- The standard concentration remains 4 mg in 250 mL D5W or dextrose-containing normal saline (16 mcg/mL) 3, 2
Critical Compatibility Considerations
Avoid contact with the following substances when preparing norepinephrine: 1
- Iron salts
- Alkalis (including sodium bicarbonate)
- Oxidizing agents
Never mix norepinephrine with sodium bicarbonate or other alkaline solutions in the IV line, as adrenergic agents are inactivated in alkaline solutions 4
Storage and Stability
- Store the diluted norepinephrine solution for up to 24 hours at room temperature [20°C to 25°C (68°F to 77°F)] 1
- Protect from light during storage 1
- Visually inspect for particulate matter and discoloration before administration—the solution should be colorless 1
- Do not use if the solution is pinkish or darker than slightly yellow, or if it contains a precipitate 1
Administration Protocol
- Infuse through a large vein, preferably via central venous access 2, 1
- Use an infusion pump for precise administration 2
- Initial dosing: 8-12 mcg/min (or 0.05-0.1 mcg/kg/min), titrated to achieve MAP ≥65 mmHg 4, 1
- Monitor blood pressure every 2 minutes until desired effect achieved, then every 5 minutes 1
Common Pitfall to Avoid
The most critical error is using normal saline without dextrose for norepinephrine dilution, as this accelerates oxidation and reduces drug potency 1. Always ensure your diluent contains dextrose, whether it's D5W, D5NS (dextrose normal saline), or other dextrose-containing crystalloid solutions.