From the Guidelines
Quad concentrating levophed (norepinephrine) in the ICU means preparing the medication at four times the standard concentration, typically 16 mg in 250 mL instead of the standard 4 mg in 250 mL. This higher concentration allows for delivery of the same dose at a lower fluid volume, which is particularly beneficial for patients who require fluid restriction such as those with volume overload, pulmonary edema, or renal failure. To quad concentrate levophed, you would use 16 mg of norepinephrine in 250 mL of D5W or normal saline, resulting in a concentration of 64 mcg/mL (compared to the standard 16 mcg/mL). When administering quad concentrated levophed, it's crucial to adjust the infusion rate accordingly - the pump rate will be one-fourth of what would be used with standard concentration to deliver the same dose. This requires careful calculation, clear labeling, and vigilant monitoring to prevent medication errors. Always use a central line for administration due to the higher risk of extravasation injury with more concentrated vasopressors, as suggested by guidelines for vasopressor use in septic shock management 1. Key considerations in vasopressor management include titrating to a mean arterial pressure (MAP) target and using norepinephrine as the first-choice vasopressor 1. Given the importance of precise dosing and potential for complications, quad concentrated levophed should be used under close supervision in an ICU setting.
From the FDA Drug Label
DOSAGE & ADMINISTRATION Norepinephrine Bitartrate Injection is a concentrated, potent drug which must be diluted in dextrose containing solutions prior to infusion. Fluid Intake: The degree of dilution depends on clinical fluid volume requirements. If large volumes of fluid (dextrose) are needed at a flow rate that would involve an excessive dose of the pressor agent per unit of time, a solution more dilute than 4 mcg per mL should be used On the other hand, when large volumes of fluid are clinically undesirable, a concentration greater than 4 mcg per mL may be necessary.
To quadruple concentrate the Levophed (Norepinephrine) in the Intensive Care Unit (ICU) means to increase the concentration of the solution to 4 times the standard concentration.
- The standard concentration is 4 mcg per mL, as stated in the average dosage section.
- Quadrupling this concentration would result in a concentration of 16 mcg per mL. This can be done when large volumes of fluid are clinically undesirable 2.
From the Research
Concentration of Norepinephrine in ICU
To quadruple concentrate the Levophed (Norepinephrine) in the Intensive Care Unit (ICU) means to increase its concentration four times the standard concentration.
Standard Concentrations
- The standard concentration of norepinephrine can vary depending on the institution and the specific patient population 3.
- Some studies suggest that using standard concentration infusions for inotropic and vasoactive drugs, including norepinephrine, can improve patient safety in pediatric intensive care units 3.
- However, the optimal concentration of norepinephrine for adult patients in the ICU is not well established and may depend on various factors, including the patient's weight, clinical condition, and the specific dosing strategy used 4.
Dosing Strategies
- Weight-based dosing strategies for vasopressors, including norepinephrine, have been evaluated in some studies, but the results are inconclusive 4.
- One study found that a weight-based dosing strategy did not improve outcomes compared to a non-weight-based strategy 4.
- Another study suggested that the use of norepinephrine was associated with lower hospital mortality in patients with severe shock, but the optimal dosing strategy was not specified 5.
Administration
- Norepinephrine can be administered peripherally or centrally, and the choice of administration route may depend on the patient's specific needs and the institution's protocols 6.
- Peripheral administration of norepinephrine may be safer and more convenient than central administration, but it may also be associated with a higher risk of adverse events 6.