What nursing guidelines should be implemented when using Levophed (norepinephrine) on a stepdown med/surg unit?

Nursing Guidelines for Norepinephrine (Levophed) Administration in Stepdown Med/Surg Units

Norepinephrine should be implemented in stepdown units with strict protocols for administration, monitoring, and management to ensure patient safety and optimal outcomes. 1, 2

Preparation and Administration Guidelines

• Norepinephrine must be diluted in dextrose-containing solutions (5% dextrose or 5% dextrose with sodium chloride) prior to infusion to prevent significant loss of potency due to oxidation 2
• Standard concentration should be 4 mg of norepinephrine in 1,000 mL of dextrose solution (4 mcg/mL) to ensure consistent dosing across the unit 2
• Administration should be through a large vein, preferably via a central venous catheter to minimize risk of extravasation and tissue necrosis 1, 2
• When central access is unavailable, a large-bore peripheral IV in a large vein can be used temporarily while central access is being established 1
• Continuous infusion pumps with accurate flow control must be used for administration to ensure precise dosing 2

Monitoring Requirements

• Implement continuous arterial blood pressure monitoring via arterial line for all patients receiving norepinephrine in the stepdown unit 1, 3
• If arterial line is not immediately available, measure blood pressure non-invasively at 5-15 minute intervals while norepinephrine is being infused 1
• Continuous cardiac monitoring is mandatory for all patients receiving norepinephrine 3
• Monitor for signs of tissue perfusion including urine output, mental status changes, skin temperature, and capillary refill 1, 3
• Regular assessment of central venous pressure (CVP) should be performed if central access is available 1
• Document vital signs at minimum hourly, with more frequent documentation during dose adjustments 4

Titration Guidelines

• Initial dose should be 2-3 mL/minute (8-12 mcg/minute) with adjustment based on patient response 2
• Target mean arterial pressure (MAP) of 65 mmHg or individualized goal based on patient's condition 1
• For previously hypertensive patients, target a systolic blood pressure no higher than 40 mmHg below their baseline 2
• Average maintenance dose ranges from 0.5-1 mL/minute (2-4 mcg/minute) but should be titrated according to patient response 2
• Weaning should be gradual to avoid abrupt withdrawal and potential hemodynamic instability 2

Staffing and Training Requirements

• Nursing staff must receive specialized training in vasopressor management before caring for patients on norepinephrine 3
• Nurse-to-patient ratios should be adjusted to ensure adequate monitoring (maximum 1:3 ratio recommended) 4
• Rapid response team should be readily available for immediate consultation if patient condition deteriorates 1
• Regular competency assessments for nurses managing norepinephrine infusions should be implemented 4

Potential Complications and Management

• Monitor closely for extravasation, which can cause severe tissue necrosis; if suspected, stop infusion immediately and notify physician 2
• Assess for signs of fluid overload as norepinephrine should be used after adequate volume resuscitation 1, 3
• Monitor for arrhythmias, which may occur with vasopressor therapy 1
• Have phentolamine available for local infiltration in case of extravasation 2
• Be vigilant for signs of organ hypoperfusion despite normalized blood pressure 1

Transfer and Escalation Criteria

• Establish clear criteria for when patients should be transferred to higher level of care (ICU) if they require escalating doses of norepinephrine 1, 3
• Consider ICU transfer if norepinephrine requirements exceed 0.2 mcg/kg/min or if patient requires multiple vasopressors 1
• Develop a protocol for rapid escalation of care if patient shows signs of deterioration despite norepinephrine therapy 3

Documentation Requirements

• Document baseline hemodynamic parameters before starting norepinephrine 4
• Record all dose changes, corresponding vital signs, and patient response 4
• Document assessment of peripheral circulation at least hourly 1
• Maintain accurate intake and output records to assess fluid status and renal perfusion 1
• Document site assessment for signs of extravasation at least hourly 2

Equipment Requirements

• Ensure availability of infusion pumps with appropriate safety features 2
• Stock emergency equipment including backup infusion pumps and pre-mixed norepinephrine solutions 3
• Implement smart pump technology with dose limits and alerts to prevent medication errors 4
• Ensure availability of central line insertion equipment for rapid central access if needed 1

By implementing these comprehensive guidelines, your stepdown med/surg unit can safely administer norepinephrine to patients requiring hemodynamic support while minimizing risks and optimizing outcomes.