What is the recommended initial drip rate for Levophed (Norepinephrine) administered peripherally in a 72 kg patient without a central line?

Levophed (Norepinephrine) Administration Guidelines for Peripheral Use

For a 72 kg patient without central access, norepinephrine should be administered at an initial rate of 0.1-0.5 mcg/kg/min (7.2-36 mcg/min) through a large peripheral vein with careful monitoring for extravasation, and should be transferred to central access as soon as possible.

Preparation and Dosing

Standard Preparation:

• Add 4 mg (4 mL) of norepinephrine to 1,000 mL of 5% dextrose solution 1
• This creates a standard concentration of 4 mcg/mL
• Do not use saline solution alone as it does not provide protection against oxidation 1

Initial Dosing:

• Start at 0.1-0.5 mcg/kg/min (7.2-36 mcg/min for a 72 kg patient) 2
• Initial flow rate: 2-3 mL/minute (8-12 mcg/min) 1
• Titrate to maintain target blood pressure (usually 80-100 mmHg systolic) 1
• Average maintenance dose: 0.5-1 mL/minute (2-4 mcg/min) 1

Peripheral Administration Guidelines

When Peripheral Administration is Acceptable:

• Only for short-term therapy (<24 hours) 2
• When central access is not immediately available
• When delay in administration would be harmful

Requirements for Peripheral Administration:

1. Vein Selection: Use a large peripheral vein, preferably in the antecubital fossa
2. Catheter Placement: Insert a plastic intravenous catheter well advanced centrally into the vein 1
3. Secure Fixation: Secure with adhesive tape, avoiding catheter tie-in techniques that promote stasis 1
4. Monitoring: Implement frequent site checks (every 1-2 hours) for signs of extravasation
5. Concentration: Use a more dilute solution (less than 4 mcg/mL) when peripheral administration is necessary 1

Contraindications for Peripheral Administration:

• Uncorrected hypovolemia (correct volume status before starting vasopressors) 2
• Anticipated need for prolonged use (>24 hours) 2
• Inability to monitor the IV site adequately 2
• Severe peripheral arterial disease 2

Monitoring and Safety

Required Monitoring:

• Continuous cardiac monitoring
• Frequent blood pressure measurements (every 5-15 minutes initially)
• Regular IV site assessment for signs of extravasation
• Use of an IV drip chamber or other metering device for accurate flow rate 1

Managing Extravasation:

• If extravasation occurs, immediately stop the infusion
• Consider infiltration with phentolamine (5-10 mg diluted in 10-15 mL of normal saline) 2
• Document and monitor the site

Important Precautions:

• Always correct hypovolemia before or concurrently with vasopressor administration 1
• For previously hypertensive patients, aim for a systolic BP no higher than 40 mmHg below their baseline 1
• Avoid abrupt withdrawal; taper gradually when discontinuing 1

Transitioning to Central Access

• Obtain central venous access as soon as possible
• Central venous access is strongly preferred for vasopressor administration 2
• When transitioning, ensure there is no interruption in the infusion
• Consider higher concentration (>4 mcg/mL) once central access is established if fluid restriction is needed 1

Special Considerations

• Individual variation in dose requirements is common; titrate according to patient response 1
• In obese patients, non-weight-based dosing may be more appropriate (similar total doses but lower weight-based doses compared to non-obese patients) 3
• Monitor for adverse effects including tachyarrhythmias, increased myocardial oxygen consumption, and lactic acidosis 2

Remember that peripheral administration of norepinephrine is a temporary measure until central access can be established. The risk of tissue necrosis from extravasation is significant, requiring vigilant monitoring of the IV site.