How to utilize a Norepinephrine (Levophed) drip?

From the Guidelines

Levophed (norepinephrine) drips should be administered through a central venous line at an initial dose of 0.1-0.5 mcg/kg/minute, titrated every 5-10 minutes to achieve the desired blood pressure target, typically a mean arterial pressure (MAP) of 65 mmHg or higher, as recommended by the 2016 Surviving Sepsis Campaign guidelines 1.

Key Considerations

• The maximum dose is generally 3 mcg/kg/minute.
• Prepare the infusion by adding 4 mg of norepinephrine to 250 mL of D5W or normal saline (resulting in 16 mcg/mL concentration).
• Always use an infusion pump for precise delivery and monitor the patient continuously with arterial line blood pressure monitoring if possible.
• Watch for extravasation which can cause tissue necrosis; if this occurs, infiltrate the area with phentolamine 5-10 mg in 10-15 mL of normal saline.

Mechanism and Indications

• Levophed works by stimulating alpha-1 adrenergic receptors causing vasoconstriction, which increases peripheral vascular resistance and blood pressure.
• It's primarily used for hypotension in septic shock, neurogenic shock, and other vasodilatory shock states after adequate fluid resuscitation has been completed, as supported by the World Journal of Emergency Surgery 1.

Titration and Weaning

• Titrate the dose every 5-10 minutes to achieve the desired blood pressure target.
• Wean the drip gradually when the patient stabilizes to prevent rebound hypotension.

Additional Recommendations

• Norepinephrine is the first-choice vasopressor, as recommended by the 2016 Surviving Sepsis Campaign guidelines 1.
• The use of vasopressors, such as norepinephrine, should be guided by the patient's hemodynamic response, as stated in the European Heart Journal 1.

From the FDA Drug Label

DOSAGE & ADMINISTRATION Norepinephrine Bitartrate Injection is a concentrated, potent drug which must be diluted in dextrose containing solutions prior to infusion. Add the content of the vial (4 mg/4 mL) of LEVOPHED to 1,000 mL of a 5 percent dextrose containing solution. Each mL of this dilution contains 4 mcg of the base of LEVOPHED Give this solution by intravenous infusion. After observing the response to an initial dose of 2 mL to 3 mL (from 8 mcg to 12 mcg of base) per minute, adjust the rate of flow to establish and maintain a low normal blood pressure (usually 80 mm Hg to 100 mm Hg systolic) The average maintenance dose ranges from 0. 5 mL to 1 mL per minute (from 2 mcg to 4 mcg of base).

To utilize a Levophed drip, the following steps should be taken:

• Dilute the Levophed in a 5 percent dextrose containing solution.
• Administer the solution by intravenous infusion.
• Start with an initial dose of 2 mL to 3 mL (from 8 mcg to 12 mcg of base) per minute.
• Adjust the rate of flow to establish and maintain a low normal blood pressure (usually 80 mm Hg to 100 mm Hg systolic).
• The average maintenance dose ranges from 0.5 mL to 1 mL per minute (from 2 mcg to 4 mcg of base) 2.

From the Research

Utilizing a Levophed Drip

To utilize a Levophed drip, which is another name for norepinephrine, several factors must be considered:

• The patient's condition, such as septic shock, and the need for vasopressor therapy to increase and maintain vascular tone and adequate tissue perfusion 3
• The dosing requirements, which may vary depending on the patient's weight, with obese patients potentially requiring lower weight-based doses 4
• The importance of tailoring therapy to the individual patient and their hemodynamic response 3
• The potential benefits of early initiation of norepinephrine, including decreased short-term mortality, shorter time to achieved target mean arterial pressure (MAP), and less volume of intravenous fluids within 6 hours 5

Key Considerations

When utilizing a Levophed drip, the following key considerations should be taken into account:

• The initial target MAP, which is typically around 65 mmHg, but may need to be individualized based on factors such as history of chronic hypertension or central venous pressure (CVP) 6
• The potential need to combine norepinephrine with other vasopressors, such as vasopressin, to achieve the target MAP or decrease the norepinephrine dosage 6
• The importance of monitoring the patient's hemodynamic response and adjusting the norepinephrine infusion rate as needed 3
• The potential benefits of using beta-1 adrenoreceptor blockers, such as esmolol, in conjunction with norepinephrine to reduce heart rate and improve cardiac output 7

Dosing and Administration

The dosing and administration of Levophed (norepinephrine) should be guided by the patient's individual needs and response:

• The typical starting dose is around 0.1-0.2 μg/kg/min, with titration to achieve the target MAP 6
• The maximum dose is typically around 1-2 μg/kg/min, although higher doses may be used in refractory cases 6
• The infusion should be administered through a central line, with careful monitoring of the patient's hemodynamic response and adjustment of the infusion rate as needed 3