Is it safe to initiate physiotherapy in a patient receiving high-dose norepinephrine (levophed)?

Safety of Physiotherapy in Patients on High-Dose Norepinephrine

Physiotherapy is generally safe in patients receiving high-dose norepinephrine, but should be approached with caution and continuous monitoring of hemodynamic parameters during the intervention.

Hemodynamic Considerations with Norepinephrine

Norepinephrine is the first-line vasopressor for managing shock, particularly distributive shock 1. It is typically administered at doses of 0.05-0.1 μg/kg/min, titrated to maintain a mean arterial pressure (MAP) ≥65 mmHg 1.

When patients are on high-dose norepinephrine:

• They have significant hemodynamic instability
• Their cardiovascular system is highly dependent on vasopressor support
• They may have limited physiological reserve to tolerate additional stressors

Evidence for Physiotherapy Safety

A multi-center prospective observational study examining physiotherapy interventions in intensive care units found:

• Only 27 adverse events occurred during 12,281 physiotherapy interventions (0.2% incidence) 2
• This incidence was significantly lower than the general adverse event rate in intensive care 2

However, common factors in patients who experienced adverse physiological changes during physiotherapy included:

• Deterioration in cardiovascular status (decreased blood pressure or arrhythmia) in patients on medium to high doses of inotropes/vasopressors
• Unstable baseline hemodynamic values
• Previous cardiac comorbidities
• Interventions consisting of positive pressure or right side lying 2

Recommendations for Safe Physiotherapy

1. Pre-intervention assessment:

   • Ensure patient has stable hemodynamics before initiating physiotherapy
   • Review current vasopressor requirements and recent dose adjustments
   • Check baseline vital signs, particularly MAP and heart rate

2. During intervention:

   • Implement continuous hemodynamic monitoring
   • Start with less intensive interventions and gradually progress
   • Avoid positions that may compromise hemodynamic stability (e.g., right side lying) 2
   • Have a low threshold for terminating the session if adverse changes occur

3. Specific precautions:

   • For patients on high-dose norepinephrine (>0.2 μg/kg/min), consider having additional staff present during the intervention
   • Ensure resuscitation equipment is readily available
   • Maintain close communication with the medical team

Risk Stratification

Higher risk patients include those with:

• Unstable or recently escalating vasopressor requirements
• MAP consistently <65 mmHg despite vasopressor therapy 1
• Multiple organ failure 3
• High lactate levels (>4 mmol/L) 3
• Cardiac comorbidities 2

Conclusion

While physiotherapy in ICU patients is generally safe with a low incidence of adverse events (0.2%), patients on high-dose norepinephrine represent a vulnerable population requiring special attention. With appropriate monitoring, risk assessment, and careful intervention selection, physiotherapy can be safely performed in these patients. The benefits of early mobilization and respiratory physiotherapy often outweigh the risks when appropriate precautions are taken.