Do you administer intravenous (IV) fluids to a patient on levophed (norepinephrine) for hypotension?

Administration of IV Fluids in Patients on Levophed (Norepinephrine)

In patients on levophed (norepinephrine) for hypotension, IV fluid administration should be prioritized before and concurrently with vasopressor therapy to correct blood volume depletion, as levophed should not be given to patients who are hypotensive from blood volume deficits except as an emergency measure. 1

Initial Fluid Resuscitation

• Before initiating vasopressors, patients should receive an initial crystalloid fluid challenge of at least 30 mL/kg 2
• Continue fluid administration as long as hemodynamic improvement is observed 2
• Balanced crystalloids are preferred for initial fluid resuscitation 2

Fluid Management During Vasopressor Therapy

Assessment of Volume Status

When managing a patient on levophed, follow this algorithm:

1. Assess for hypovolemia - Look for:

   • Clinical signs of dehydration
   • Low central venous pressure (if available)
   • Fluid responsiveness parameters
   • History of fluid losses (bleeding, vomiting, diarrhea, etc.)

2. If hypovolemic: Administer IV fluids to achieve normovolemia 3

   • This is critical as the FDA label explicitly warns that levophed should not be given to patients who are hypotensive from blood volume deficits except as an emergency measure 1

3. If euvolemic or hypervolemic: Monitor hemoglobin as clinically indicated 3

   • In this case, focus on vasopressor optimization rather than additional fluid administration

Cautions and Contraindications

The FDA label for levophed specifically warns about the risks of continuous administration without adequate blood volume replacement 1:

• Severe peripheral and visceral vasoconstriction
• Decreased renal perfusion and urine output
• Poor systemic blood flow despite "normal" blood pressure
• Tissue hypoxia and lactate acidosis

Special Considerations

Cardiogenic Shock/Heart Failure

• In patients with acute heart failure and signs of hypoperfusion, diuretics should be avoided before adequate perfusion is attained 3
• The initial approach to congestion management involves IV diuretics with vasodilators for dyspnea relief if blood pressure allows 3

Administration Method

• When administering levophed, it should be diluted in dextrose-containing solutions (5% dextrose injection or 5% dextrose and sodium chloride injections) 1
• Administration in saline solution alone is not recommended 1
• If whole blood or plasma is indicated to increase blood volume, it should be administered separately 1

Monitoring During Combined Therapy

During concurrent administration of IV fluids and levophed:

• Monitor blood pressure and heart rate continuously
• Assess urine output hourly
• Evaluate skin perfusion and mental status regularly
• Monitor lactate clearance and renal/liver function tests 2
• Consider arterial blood pressure measurement 3

Common Pitfalls to Avoid

1. Failing to correct hypovolemia: Levophed is not a substitute for volume replacement. Administering vasopressors without adequate fluid resuscitation can worsen tissue perfusion and lead to organ damage.

2. Volume overload: Excessive fluid administration can lead to pulmonary edema, especially in patients with cardiac dysfunction.

3. Abrupt discontinuation: Infusions of levophed should be reduced gradually, avoiding abrupt withdrawal 1

4. Peripheral administration risks: When administering through peripheral IV access, monitor closely for extravasation which can cause tissue necrosis 4

In summary, IV fluid administration is essential in patients on levophed, particularly before and during initial vasopressor therapy to ensure adequate intravascular volume. The approach should be guided by careful assessment of volume status, with the goal of maintaining adequate tissue perfusion while avoiding the complications of either hypovolemia or fluid overload.