What is the dose of norepinephrine (Levophed) for treating hypotension?

From the Guidelines

Norepinephrine (Levophed) should be initiated at a dose of 0.1–0.5 mcg/kg/min for treating hypotension.

Key Considerations

• The dose should be titrated to effect, with a target mean arterial pressure (MAP) of 65 mm Hg 1.
• Norepinephrine is the first-choice vasopressor for treating hypotension, especially in septic shock 1.
• The use of norepinephrine should be guided by hemodynamic monitoring, including arterial and central venous catheters, to optimize volume status and cardiac function 1.
• Vasopressin can be added as a second-line agent when increasing doses of norepinephrine are required 1.
• The dose of norepinephrine may need to be individualized based on the patient's condition, with consideration of factors such as cardiac output, blood pressure, and end-organ perfusion 1.

Additional Guidance

• Dopamine can be used as an alternative vasopressor in highly selected patients, such as those with low risk of tachyarrhythmias and absolute or relative bradycardia 1.
• Phenylephrine is not recommended as a first-line agent for treating septic shock, except in specific circumstances such as serious arrhythmias or high cardiac output with low blood pressure 1.
• Low-dose dopamine should not be used for renal protection 1.

From the FDA Drug Label

DOSAGE & ADMINISTRATION ... Average Dosage: 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) sufficient to maintain the circulation to vital organs

The average maintenance dose ranges from 0. 5 mL to 1 mL per minute (from 2 mcg to 4 mcg of base).

The dose of norepinephrine (Levophed) for treating hypotension is:

• Initial dose: 8 mcg to 12 mcg of base per minute (2 mL to 3 mL per minute)
• Average maintenance dose: 2 mcg to 4 mcg of base per minute (0.5 mL to 1 mL per minute) 2

From the Research

Norepinephrine Dosing for Hypotension

• The dose of norepinephrine for treating hypotension can vary depending on the patient's condition and response to treatment 3, 4.
• In cases of refractory hypotension, increasing norepinephrine up to doses ≥1 µg/kg/min could be an option 3.
• The optimal blood pressure target is typically a mean arterial pressure (MAP) of at least 65 mmHg, with higher values targeted in cases of chronic hypertension 3, 4.
• When hypotension is refractory to norepinephrine, adding vasopressin is recommended, as it acts on different vascular receptors than α1-adrenergic receptors 3, 4.

Comparison of Norepinephrine with Other Vasopressors

• Norepinephrine is approximately 11 times more potent than phenylephrine when used as bolus doses for treatment of hypotension 5.
• The conversion dose ratio between norepinephrine and angiotensin II is around 10:1 in patients with vasodilatory hypotension 6.

Clinical Considerations

• Early administration of norepinephrine is beneficial for septic shock patients to restore organ perfusion 7, 4.
• The dose of norepinephrine should be individualized based on the patient's response to treatment and underlying condition 3, 4.