What is the proper administration of a push dose of Levophed (norepinephrine) in a clinical setting?

Push Dose Norepinephrine Administration

Push dose norepinephrine is not recommended for clinical use; instead, norepinephrine should be administered as a properly diluted continuous infusion through a large vein, preferably central, with careful titration to achieve hemodynamic goals. 1, 2

Proper Preparation and Administration of Norepinephrine

Standard Dilution and Administration

• Norepinephrine must be diluted in dextrose-containing solutions prior to infusion 2
• Standard dilution: Add 4 mg (4 mL) of norepinephrine to 1,000 mL of 5% dextrose solution, creating a 4 mcg/mL concentration 2
• Administration route:
  • Preferably through a central venous catheter 1
  • If peripheral administration is necessary, use an 18-20G catheter in a medium-to-large caliber vein (antecubital fossa or above) 1
  • Always verify blood return before starting infusion 1

Dosing Guidelines

• Initial dose: 0.1-0.5 mcg/kg/min (typically 2-12 mcg/min or 0.5-3 mL/min of standard dilution) 1, 2
• Titrate every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min 1
• Target mean arterial pressure (MAP) of 65 mmHg 1
• Maximum dose: Up to 1 mcg/kg/min; doses >1.13 mcg/kg/min are associated with increased mortality 3

Why Push Dose Administration Is Not Recommended

1. Safety concerns:

   • Risk of severe hypertension and arrhythmias with rapid bolus administration 1
   • Potential for tissue ischemia and necrosis if extravasation occurs 1, 4
   • Difficulty in precise dosing with manual push administration

2. Pharmacokinetic considerations:

   • Norepinephrine has a very short half-life (1-2 minutes)
   • Continuous infusion provides more stable hemodynamic effects than intermittent boluses

3. Monitoring requirements:

   • Continuous hemodynamic monitoring is essential during norepinephrine administration 1
   • Push dosing makes appropriate monitoring and titration difficult

Alternative Emergency Approach When Infusion Pump Not Immediately Available

If faced with an emergent situation requiring immediate vasopressor support before an infusion can be prepared:

1. Prepare a more dilute solution:

   • Add 1 mg (1 mL) of norepinephrine to 100 mL of normal saline, creating a 10 mcg/mL solution 1
   • This allows for more controlled administration than pure push dosing

2. Administer via slow IV push or micro-drip:

   • Start with 0.5-1 mL (5-10 mcg) over 1-2 minutes
   • Monitor blood pressure response continuously
   • Repeat as needed while preparing standard infusion

3. Transition to standard infusion as soon as possible

Critical Monitoring During Administration

• Continuous electrocardiographic monitoring 1
• Frequent blood pressure measurements (every minute if continuous monitoring unavailable) 1
• Regular inspection of infusion site for signs of extravasation 1, 4
• Monitor for:
  • Excessive hypertension (systolic BP >220 mmHg)
  • Bradycardia (<40 beats/min)
  • Signs of peripheral ischemia 4

Management of Complications

• Extravasation: Immediately stop infusion and infiltrate the area with 5-10 mg of phentolamine diluted in 10-15 mL of saline 1
• Excessive hypertension: Temporarily stop infusion and restart at lower dose once BP normalizes
• Arrhythmias: Consider reducing dose or switching to alternative vasopressor 5

Important Caveats

• Always correct hypovolemia before initiating norepinephrine 1
• Avoid abrupt discontinuation; taper gradually 2
• Never mix with alkaline solutions like sodium bicarbonate 1
• Use caution in patients with ischemic heart disease due to increased myocardial oxygen demand 1
• Patients on beta-blockers may require higher doses or alternative agents 1

The "double pumping" or "piggybacking" technique is recommended when transitioning between infusion bags to ensure uninterrupted administration 6.