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 Guidelines for Norepinephrine

• Initial dose: 0.05-0.1 μg/kg/min
• Titration: Increase by 0.05-0.1 μg/kg/min every 5-15 minutes
• Target: MAP ≥65 mmHg
• Maximum dose: Not strictly 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 acceptable in some cases when central access is not immediately available 3
• Early administration of norepinephrine is beneficial as it:
  • Rapidly increases and better stabilizes arterial pressure
  • Increases cardiac output
  • Improves microcirculation
  • Helps avoid fluid overload 4, 5

When to Consider Early Norepinephrine

Early administration of norepinephrine should be considered in patients with:

• Profound hypotension (e.g., diastolic BP ≤40 mmHg)
• High diastolic shock index (heart rate/diastolic blood pressure ≥3)
• Risk of fluid accumulation
• Conditions where fluid accumulation would be particularly harmful (ARDS, intra-abdominal hypertension) 4

Monitoring Parameters

While on norepinephrine therapy, monitor:

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

Management of Refractory Hypotension

If hypotension persists despite norepinephrine:

1. Add vasopressin (maximum dose 0.03 U/min) to raise MAP or decrease norepinephrine dosage 1, 2
2. Consider epinephrine if there's evidence of myocardial depression 1, 6
3. Consider hydrocortisone (up to 300 mg/day) if escalating vasopressor doses are required 1

Important Caveats and Pitfalls

• Dopamine is no longer recommended in septic shock due to higher rates of cardiac arrhythmias 6
• Duration and depth of hypotension strongly worsen outcomes in septic shock patients 4
• Relying solely on fluids to restore blood pressure in profound hypotension may unduly prolong hypotension and organ hypoperfusion 4
• In patients with chronic hypertension, consider targeting a higher MAP 5
• Monitor closely for signs of myocardial dysfunction, myocardial ischemia, and other complications, especially in those with cardiac conditions 1
• Watch for potential adverse effects including digital ischemia and tissue necrosis, particularly with peripheral administration 3