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

Maximum Dose of Levophed (Norepinephrine) for Hypotension

The maximum dose of norepinephrine (Levophed) for treating hypotension is 0.5 mcg/kg/min or up to 20 mcg/min, as recommended by current clinical guidelines. 1

Dosing Guidelines

Initial Dosing

• Start at 0.1-0.5 mcg/kg/min, titrated according to patient response 1
• Alternatively, begin with 2-3 mL/min (8-12 mcg/min) of a standard dilution (4 mg in 1,000 mL of 5% dextrose solution) 2
• Target a mean arterial pressure (MAP) of 65 mmHg in most patients 1
• For previously hypertensive patients, aim for a systolic blood pressure no higher than 40 mmHg below the preexisting systolic pressure 2

Titration

• Adjust dose every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min 1
• Average maintenance dose ranges from 2-4 mcg/min (0.5-1.0 mL/min of standard dilution) 2
• Titrate according to the individual patient's response, as there is significant variation in required doses 2

Maximum Dosing

• Maximum recommended dose: 0.5 mcg/kg/min or up to 20 mcg/min 1
• In exceptional circumstances, much higher doses (up to 68 mg or 17 vials per day) may be necessary if the patient remains hypotensive 2
• However, when extremely high doses are required, occult blood volume depletion should always be suspected and corrected 2

Administration Considerations

Preparation

• Standard dilution: Add 4 mg (4 mL) of norepinephrine to 1,000 mL of 5% dextrose solution (resulting in 4 mcg/mL) 2
• Must be diluted in dextrose-containing solutions (5% dextrose or 5% dextrose with sodium chloride) to prevent oxidation and potency loss 2
• Administration in saline solution alone is not recommended 2

Administration Route

• Administer via a large vein, preferably through a central venous catheter 2
• If using peripheral access (in emergent situations), use an 18-20G catheter in medium-to-large caliber veins 1
• Verify blood return before starting the infusion 1

Duration

• Maximum duration is less than 24 hours (ideally less than 12 hours) for peripheral administration 1
• Reduce infusion gradually to avoid abrupt withdrawal and rebound hypotension 2

Monitoring Requirements

• Continuous electrocardiographic monitoring 1
• Frequent blood pressure measurements (every minute if continuous monitoring unavailable) 1
• Regular inspection of the infusion site to detect early signs of extravasation 1
• Consider central venous pressure monitoring in patients requiring high doses to detect occult volume depletion 2

Special Considerations

Weight-Based Dosing

• Obese patients may require lower weight-based doses compared to non-obese patients (0.09 μg/kg/min vs. 0.13 μg/kg/min), though total non-weight-based doses are similar 3

Potential Complications

• Extravasation risk (2.3-4.5% with peripheral administration) requiring immediate cessation and phentolamine infiltration 1
• Supraventricular arrhythmias, especially in patients with cardiac conditions 1
• Increased myocardial oxygen consumption, which may worsen ischemia in coronary artery disease 1
• Decreased cardiac output in some patients due to increased afterload 1
• Renal and mesenteric vasoconstriction potentially impairing organ perfusion 1

Important Precautions

• Always correct hypovolemia before or concurrently with norepinephrine administration 2
• Avoid contact with iron salts, alkalis, or oxidizing agents as they may inactivate norepinephrine 2
• Never mix with alkaline solutions like sodium bicarbonate 1
• In patients on beta-blockers who are unresponsive to norepinephrine, consider IV glucagon (1-2 mg) 1

Remember that while guidelines provide maximum dose recommendations, the actual dose needed should be determined by the patient's response to treatment, with careful monitoring of hemodynamic parameters throughout administration.