Here is the ASHP IV Adult Continuous Infusions recommendations for norepinephrine influsions:
Norepinephrine
4 mg in 250 mL = 16 mcg/mL, 8 mg in 250 mL = 32 mcg/mL, 32 mg in 250 mL = 128 mcg/mL.
The higher concentration is needed for hospitals with large trauma centers and/or severe fluid restriction in critically ill with high dosing needs
And here is the infusion solution that norepinephrine should be given in:
Norepinephrine is primarily used to restore and maintain blood pressure in a variety of situations. The product monograph for one brand of this drug, Levophed, indicates that it should be administered in solutions containing 5% dextrose to limit the significant loss of potency through oxidation.
Stability of Norepinephrine Solutions in Normal Saline and 5% Dextrose in Water. Can J Hosp Pharm. 2010 Mar-Apr;63(2):113–118. doi: 10.4212/cjhp.v63i2.896
And here is PressorDex Critical Care Medication Guide, 4th Edition, 2020 on norepinephrine for septic shock [after appropriate volume resuscitation], pp 74-76:
Vasopressors: Goal: MAP > 65
Norepinephrine (NE): First line
- Infusion: 0.05 mcg/kg/min IV, titrate by 0.02 mcg/min q 5min:
- Dose range: 0.05-0.5 mcg/kg/min; Onset: 1-2 min; Dration: 1-2 min
Today, I review, link to, and embed Norepinephrine: How High Can You Go? from CriticalCareNow.
All that follows is from the above resource.
May 10, 2024 ResusX:PodcastIn this lecture from ResusX: Reset, Dr. Salim Rezaie delves into the question of maximum dosages for norepinephrine in critical care scenarios. Through an analysis of retrospective studies and a notable case report, Dr. Rezaie elucidates the lack of consensus and empirical evidence regarding the upper limits of norepinephrine administration.
Despite the absence of randomized clinical trials, retrospective data reveals survival rates ranging from 17% to 52% even at doses exceeding conventional thresholds. Notably, a case report documents successful outcomes at an unprecedented dosage of 30 micrograms per kilogram per minute.
Dr. Rezaie emphasizes the necessity of vigilant patient assessment and exploration of underlying etiologies in cases of escalating norepinephrine requirements. Stressing the importance of judicious use, he advocates for a cautious approach, typically initiating additional interventions such as stress dose steroids and vasopressin alongside norepinephrine escalation.
The discourse concludes with a call for further discussion and debate within the critical care community, acknowledging the complexity and variability inherent in managing vasopressor therapy in critically ill patients.
00:00 Introduction to Norepinephrine Dosage Debate
00:57 Exploring the Maximum Dose of Norepinephrine
01:13 Review of Retrospective Studies and Case Reports
06:22 Clinical Insights and Management Strategies
08:41 Concluding Thoughts on Norepinephrine Dosage
To watch more videos from the ResusX: Reset conference, check out https://www.resusx.com/resusx-reset-r…
5:25 – 6:23
6:23 – 8:39 [Review the transcript for this time period]
8:45 – 9:51 [Review the transcript for this time period]
