How do you prepare a norepinephrine drip for a patient?

How to Prepare a Norepinephrine Drip

Standard Adult Concentration

Add 4 mg of norepinephrine to 250 mL of D5W to yield a concentration of 16 μg/mL, which is the standard adult preparation. 1

• This concentration is stable for seven days at room temperature under ambient light in either D5W or normal saline 2
• Alternative concentration: Add 1 mg of norepinephrine to 100 mL of saline to create 10 μg/mL concentration 1

Initial Dosing and Administration

Start the infusion at 0.5 mg/h (approximately 8-12 mcg/min or 0.1-0.5 mcg/kg/min) via continuous IV infusion, preferably through central venous access. 1

• For weight-based dosing: 0.02-0.1 mcg/kg/min is the typical starting range 1
• Titrate every 4 hours by 0.5 mg/h increments to a maximum of 3 mg/h 1
• Target mean arterial pressure (MAP) of 65 mmHg for most patients 1

Critical Pre-Administration Requirements

Administer a minimum 30 mL/kg crystalloid bolus before or concurrent with norepinephrine initiation to prevent severe organ hypoperfusion from vasoconstriction in hypovolemic patients. 1

• Use balanced crystalloids (lactated Ringer's or Plasma-Lyte) preferentially over normal saline 1
• In severe hypotension (systolic <70 mmHg), start norepinephrine as an emergency measure while fluid resuscitation continues 1

Administration Route and Line Selection

Central venous access is strongly preferred to minimize extravasation risk and tissue necrosis. 1

• If central access is unavailable or delayed, peripheral IV or intraosseous administration can be used temporarily 1
• Place an arterial catheter as soon as practical for continuous blood pressure monitoring 1
• Do not mix norepinephrine with sodium bicarbonate or other alkaline solutions in the IV line, as catecholamines are inactivated in alkaline solutions. 1

Monitoring Protocol

Monitor blood pressure and heart rate every 5-15 minutes during initial titration. 1

• Assess tissue perfusion markers: lactate clearance, urine output >50 mL/h, mental status, capillary refill 1
• Watch for signs of excessive vasoconstriction: cold extremities, decreased urine output 1
• Monitor for potential side effects including hypertension, arrhythmias, and tissue ischemia 1

Extravasation Management

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

• Pediatric dose: 0.1-0.2 mg/kg up to 10 mg diluted in 10 mL of 0.9% sodium chloride 1
• This must be done as soon as possible to prevent tissue death and sloughing 1

Escalation Strategy for Refractory Hypotension

When norepinephrine reaches 0.25 mcg/kg/min and hypotension persists, add vasopressin 0.03-0.04 units/min as second-line therapy. 1

• Do not increase vasopressin above 0.03-0.04 units/min; reserve higher doses for salvage therapy only 1
• Epinephrine 0.1-0.5 mcg/kg/min can be added if needed 1
• For persistent hypoperfusion despite adequate vasopressors, add dobutamine up to 20 mcg/kg/min, particularly with myocardial dysfunction 1

Pediatric Preparation and Dosing

For pediatric patients, use the "Rule of 6": multiply 0.6 × body weight (kg) to get the number of milligrams, then dilute to 100 mL of saline; then 1 mL/h delivers 0.1 mcg/kg/min. 1

• Starting dose: 0.1 mcg/kg/min, titrated to desired clinical effect 1
• Typical range: 0.1-1.0 mcg/kg/min 1
• Maximum doses up to 5 mcg/kg/min may be necessary in some children 1

Common Pitfalls to Avoid

• Never start norepinephrine without adequate fluid resuscitation, as vasoconstriction in hypovolemic patients causes severe organ hypoperfusion despite "normal" blood pressure 1
• Do not use dopamine as first-line agent, as it is associated with higher mortality and more arrhythmias compared to norepinephrine 1
• Do not use low-dose dopamine for "renal protection", as it provides no benefit 1
• Do not use phenylephrine as first-line therapy, as it may raise blood pressure while worsening tissue perfusion 1

Special Clinical Scenarios

For anaphylaxis not responding to epinephrine and volume resuscitation, use the alternative 1:100,000 solution (1 mg in 100 mL saline) administered at 30-100 mL/h (5-15 mcg/min). 1

• For hepatorenal syndrome: Start at 0.5 mg/h, increase every 4 hours by 0.5 mg/h to maximum 3 mg/h, targeting MAP increase ≥10 mmHg and/or urine output >50 mL/h 1
• For septic shock: Norepinephrine is the mandatory first-choice vasopressor with strong recommendation 1, 3