Exploration of Norepinephrine Dose-Capping Practices: Report From an International, Interprofessional Survey of Critical Care Clinicians

Abstract

Purpose: The Joint Commission standards for titrated infusions require specification of maximum rates of infusion. This practice has led to the development of protocolized maximum doses that can be overridden by provider order (“soft maximums”) and to dose caps that cannot be superseded (“hard maximums”). The purpose of this study was to determine the prevalence of and attitudes towards dose capping of norepinephrine. Methods: A 20-item cross-sectional survey assessing norepinephrine dose capping practices, perceptions of norepinephrine protocols, and respondent and practice site demographics was distributed electronically to the mailing list of an international medical podcast. Responses were stratified according to use of weight-based dosing (WBD) or non-WBD of norepinephrine. The primary objective was to characterize norepinephrine dosing practices including protocolized maximum doses and/or dose capping. Categorical and continuous variables were compared using the Chi-square test and Mann-Whitney U test, respectively, with P < .05 indicating statistical significance. Results: The survey was completed by 586 physicians, nurses, pharmacists, and advanced practice providers. WBD was used by 51% and non-WBD by 47%. A standardized titration protocol was reported by 65% and dose capping was reported by 19%. The protocolized maximum dose ranged from 20-400 mcg/min for respondents using non-WBD (median [interquartile range] 30 [30-50]) and ranged from .2-10 mcg/kg/min for respondents using WBD (1 [.5-3]). The dose cap was 50 (40-123) mcg/min with non-WBD and 2 (1-3) mcg/kg/min with WBD. Conclusions: An international, multi-professional survey of critical care and emergency medicine clinicians revealed wide variability in norepinephrine dosing practices including maximum doses allowed.