What is the recommended use and dosage of Levophed (norepinephrine) in treating hypotension due to septic shock?

Recommended Use and Dosage of Levophed (Norepinephrine) in Septic Shock

Norepinephrine is the first-choice vasopressor for managing septic shock, with a recommended initial dosage of 0.05-0.1 μg/kg/min, titrated by 0.05-0.1 μg/kg/min every 5-15 minutes to achieve a target mean arterial pressure (MAP) ≥65 mmHg. 1

Dosing Protocol for Norepinephrine in Septic Shock

• Initial dose: 0.05-0.1 μg/kg/min
• Titration: Increase by 0.05-0.1 μg/kg/min every 5-15 minutes
• Target: Mean arterial pressure (MAP) ≥65 mmHg
• Maximum dose: No absolute maximum defined, but doses above 1 μg/kg/min are associated with mortality rates over 80% 2

Administration Considerations

• Arterial line monitoring should be established when using vasopressors 1
• While central venous administration is preferred, peripheral administration may be considered in emergent situations when central access is not immediately available 3
• Early administration of norepinephrine is beneficial as it:
  • Rapidly corrects profound hypotension (which independently increases mortality)
  • Increases cardiac output
  • Improves microcirculation
  • Helps avoid fluid overload 4, 5

Monitoring Parameters During Treatment

• Blood pressure (target MAP ≥65 mmHg)
• Heart rate
• Urine output (target ≥0.5 ml/kg/h)
• Skin perfusion
• Mental status
• Lactate clearance
• Renal and liver function tests
• SpO₂ (target ≥95%) 1

When to Consider Second-Line Agents

If hypotension persists despite escalating norepinephrine doses:

1. Add vasopressin (maximum dose 0.03 U/min) to raise MAP or decrease norepinephrine requirements 1, 2
2. Consider epinephrine if there's evidence of myocardial depression 1, 6
3. Consider dobutamine (2.5-20 μg/kg/min) for myocardial dysfunction or persistent hypoperfusion despite adequate blood pressure 1

Special Considerations

• For patients with chronic hypertension, consider a higher MAP target 5
• Early norepinephrine administration should be prioritized in patients with:
  • Profound hypotension (diastolic BP ≤40 mmHg)
  • High diastolic shock index (heart rate/diastolic blood pressure ≥3)
  • Risk of fluid accumulation
  • Conditions where fluid overload would be particularly harmful (ARDS, intra-abdominal hypertension) 4
• Consider hydrocortisone (up to 300 mg/day) if escalating vasopressor doses are required 1

Common Pitfalls to Avoid

• Delayed vasopressor initiation: Don't wait for complete fluid resuscitation before starting norepinephrine in profound shock 4, 5
• Inadequate monitoring: Always establish arterial line monitoring when using vasopressors 1
• Using dopamine: Dopamine is no longer recommended in septic shock due to higher rates of cardiac arrhythmias without mortality benefit 6
• Excessive fluid administration: Early norepinephrine can reduce the volume of fluids required and prevent complications of fluid overload 4
• Failure to recognize refractory shock: Consider adding second-line agents before norepinephrine exceeds 1 μg/kg/min 2